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Figure 56.6  An elasticized bandage is used to wrap around the shoulder
(axilla) joints in a ‘figure-of-eight’ fashion to extend and to abduct the
shoulder joints. An axillary pad is included in the wrapping to increase the
pressure upon the axillary fold.
Figure 56.7  An ‘airplane’ splint made of thermoplastic materials is used to
maintain the shoulder abduction. The angle of separation may be increased,
as the joint becomes more mobile.
Figure 56.5  A ‘3-point’ extension splint can be also used to manage the
flexion contractures of a knee joint.
Management during the intermediate phase
of recovery
A period starting from the 2nd month following the injury
through the 4th month is considered as the intermediate phase
of recovery from burn injuries. The burn victims typically
will have full recovery of physiologic functions with integu­
mental integrity restored. The cicatricial processes around
the injured sites, on the other hand, are physiologically
active though healing of the burned wound is considered
satisfactory. That is, the process is characterized by, in addi­
tion to a maximal rate of collagen synthesis, a steady increase
in the myofibroblast fraction of the fibroblast population in
the wound;7 the cellular change believed to account for con­
traction of the scar tissues. Continuous use of splinting and
pressure to support the joints and burned sites, in this sense,
is essential in order to control changes caused by ensuing
scar tissue formation and scar contracture.
Bodily positioning and joint splinting
Joint splinting and bodily positioning are similar to the
regimen used during the acute phase of burn recovery. That
is, the shoulder is kept at 15–20 degree flexion and 80–120
degree abduction. A ‘figure-of-eight’ wrapping over an axil­
lary pad is used to maintain this shoulder joint position (Fig.
56.6). The elbow and knee joints are maintained in full
extension by means of a three-point extension splint or
brace. A pressure dressing or garment is incorporated in the
splint. In instances where the use of ‘figure-of-eight’ bandage,
pressure dressing and/or garment, is not feasible because of
recent surgery, devices such as an ‘airplane splint’ device (Fig.
56.7), or a three-point extension splint may be used to splint
the axilla, elbow and the knee joints.
Pressure dressing
A compression dressing, originally incorporated in the treat­
ment of burned wounds of the upper and lower extremities
at the Shriners Burns Hospital in 1968 as a means to provide
mechanical support to healing wounds, is effective in reduc­
ing tissue swelling and in promoting softening of a burned
scar. Compression of a burned wound even though healing

Management of contractural deformities involving the shoulder (axilla), elbow, hip and knee joints in burned patients
635
The joint stiffness caused by scar contracture may be further
aggravated by physical inactivity, especially if the patient is
allowed to remain in the posture of ‘comfort’.
There are two non-surgical methods commonly used to
mobilize a contracted shoulder (axilla) joint. One is ‘figure
of eight’ compression dressing technique and the other an
‘airplane’ splinting technique;
A ‘figure-of-eight’ compression dressing
An elasticized bandage is used to wrap over a pad placed in
the axillary fold around the shoulder joint in a ‘figure-of-
eight’ fashion to extend and abduct the shoulder. The dress­
ing must be worn continuously and it is removed only for
cleansing. Continuous wear of the dressing for a period of
3–6 months is necessary to obtain the release. The mobility
of the joint increases as the scar tissues across the axilla
softens. The extent of relief may be limited if the scar is thick
and unyielding to the pressure (Fig. 56.8).
An airplane splint
The splint is fabricated with a thermoplastic material. The
spreading angle of the splint is conformed to the extent of
the shoulder (axilla) joint held at maximum abduction plus
10–15 degrees of extension. Abduction and extension of the
joint, that is elevation of the arm, will be maintained by
‘pushing’ the arm away from the upper thorax. Care is
needed to protect the skin over the inner aspect of the arm
and the side of the chest. The splint is changed regularly as
the angle of joint abduction increases. To achieve the needed
release in most instances, 1–3 months of continuous use of
this device is usually necessary (Fig. 56.7).
Elbow and knee contracture
Flexion contracture is the most common deformity encoun­
tered in these two joints. The scar formed across the antecu­
bital and the popliteal fossae frequently aggravates the
magnitude of contractural problems in these joints. The fol­
lowing techniques are frequently utilized before surgery to
obtain joint movement and joint extension:
A three-point extension splint
The splint is assembled similarly to a prosthetic/orthotic
device. Two sidebars hinged at the middle are connected
with a bracing trough at the end. A cap pad is attached at
the mid-section of the sidebar to fit over the elbow or the
kneecap. The splint is placed across the antecubital fossa or
the popliteal fossa. Fitting of the splint is adjusted with the
Velcro straps (Figs 56.2, 56.3).
The amount of extension achieved by the joint is deter­
mined by the extent of pre-existing joint stiffness. The angle
of extension is initially determined by the angle of joint
contracture. The magnitude of extension is controlled by
tightening the olecranon or patellar pad. It is increased grad­
ually as the joint gains its mobility. The problems encoun­
tered with the use of a ‘three-point extension splint’ are
uncommon. However, breakdown of the skin can occur.
Leverage attainable from 3-point pressure application may
be limited in a young individual because of short limb
length. The skeletal traction technique, in such instances,
may be used.
is still in progress, is most easily achieved by means of wrap­
ping the extremity with an elasticized bandage. Wrapping of
the extremity should begin at the hand or foot. The bandage
is moved cephalad in a criss-cross fashion. The splint is
reapplied over the bandage. It is important to rewrap the
extremity three to four times daily. Wrapping an extremity
with an elasticized bandage can produce a pressure ingredi­
ent of 10–25 mm Hg.5,8 The use of a pressure dressing should
be continued for 12 to 18 months.
Surgical management of established
contractural deformities
Contraction of the shoulder, elbow, hip and knee joints can
occur despite proper splinting and intensive physical therapy.
Surgical reconstruction of contractural deformities, in this
sense, remains an essential component of patient care and
patient rehabilitation. The task of deciding the timing of
surgical intervention, however, can be difficult and it requires
detailed evaluation of the patient and the deformity. The
following are ascertained before surgery:
1. The causes of joint immobility
2. The extent and the availability of uninjured skin that
could be used for reconstruction
3. The extent of maturation of scar tissues that surround
the joint.
Patient evaluation
There are numerous factors that will affect joint movements
in burn patients. Although hypertrophy and contraction of
scar tissues and/or contracted skin graft around a joint are
the most common causes of joint impairment, changes in
the ligamentous structures or the joint itself due to burn
injuries could also limit the joint mobility. Detailed exami­
nation that includes radiographic assessment of the joint
structures is essential in order to formulate a definitive treat­
ment plan.
Non-operative or minimally invasive approach
to correct a contracted and/or stiff joint
Restoration of movements in a contracted and/or stiff joint
could be attained by minimally invasive or non-surgical
means.2–6 ‘Pushing’ and ‘pulling’ of an extremity that in turn,
‘stretches’ contracted scars and tissues around an affected
joint is the principle behind this modality of managing a
contracted and/or stiff joint. The treatment is found to be
especially effective in mobilizing a contracted joint caused
by a long period of physical inactivity or in some instances,
of scar contracture.
Although the morbidities associated with this modality of
treatment are minimal, breakdown of the skin due to pres­
sure and/or friction resulting from ‘pushing’ and ‘pulling’ of
a limb can occur.
Shoulder (axillary) contracture
Tight scars formed across the shoulder joint, usually in the
area along the axillary folds, often limit the joint movement.

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Figure 56.8  (a) A 6-year-old boy sustained burns of the right side of his body extending from the lower neck to the upper thorax that included the axillary
crease. (b) He experienced difficulty in extending both the neck and the right arm because of ensuing contraction of scar tissues around the neck and the
axilla. (c) A ‘figure-of-eight’ dressing was used to maintain the shoulder extension and abduction. The dressing was used for 12 months. (d) He regained the
shoulder extension and mobility with the use of pressure dressing.
A
B
C
D
A skeletal traction technique
Utilizing a skeletal traction technique to restore movements
in a contracted joint typically requires percutaneous inser­
tion of a Steinman’s pin through the radius for the elbow
joint and the tibia for the knee joint. The pin is inserted
through both cortices at the junction of proximal two-thirds
and the distal third of the radius or the tibia. A contracted
joint can be mobilized by continuous and constant ‘pull’
of the long bone utilizing gravitational force generated with
10–15 pounds of weight placed through a pulley device.
For a flexion deformity of the elbow, the patient is placed
in a supine position. The pulley traction device will provide
a horizontal and then a vertically downward pull (Fig. 56.9).
A weight placed around the ankle with the patient being
placed in a prone position, instead of a skeletal traction
device, may be used to pull the foreleg to loosen a contracted
knee. This technique is especially useful in treating
indi­viduals with a limited knee flexion contracture. Traction
is continued for a period of time and is repeated several
times a day (Fig. 56.10).
Although the morbidities due to infection are uncommon,
continuous and constant force of pull can cause break down
of the skin typically located in the area across the joint
surface. The wound can be temporarily covered with surgical
dressing or biological dressing. Closure of the wound is
contemplated once the joint contracture is fully corrected.

Management of contractural deformities involving the shoulder (axilla), elbow, hip and knee joints in burned patients
637
Figure 56.9  A contractural deformity had developed involving the left elbow joint. There were no direct injuries involving the joint. A Steinmann’s pin
was inserted through the distal third of the radius for traction. A 500 g weight was used. A full extension of the contracted elbow joint was completed in
3–4 days.
A
B
C
D
Figure 56.10  A knee contracture developed in an 8-year-old boy due to improper positioning and immobilization of the knee joint. There were no direct
injuries involving the knee area. With the patient being placed in a prone position, the ankle was strapped with a 10–15 pound weight. The flexion
contracture was relieved in 3 days.
A
B
Surgical treatment of a contracted joint
Surgical treatment of a contracted joint is contemplated
in individuals where the use of non-surgical treatment is
ineffective and where functional integrity of a joint is at
jeopardy. Surgical intervention, in this regard, is relatively
unusual during the acute phase of recovery. Instead, the
reconstruction is delayed until the scar tissue becomes
fully ‘matured’, i.e. with flattening and softening of the
scar tissue.
Pre-surgical evaluation
The patient is seen and the involved joint is examined before
surgery. The following features are assessed:
•
The extent of joint contracture is determined and the
passive and active range of joint motion is assessed.
Radiographic evaluation may be obtained to delineate
structural integrity of the joint.
•
The magnitude of scarring and scar thickness is assessed.
The scar is usually thickest across the joint surface.

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•
The location and the size of uninjured skin are
delineated. The availability of uninjured skin
frequently determines the technique of reconstruction.
Skin graft and skin flap donor site is also ascertained.
•
The point and the axis of joint rotation are located. The
line of incisional release is in alignment with the axis
of joint movement.
Techniques of joint contracture release
Despite detailed examination before surgery, exact cause
of joint stiffness can only be delineated with surgery. In
practice, contraction of the scar tissues across the joint
structure is the most common cause of contractural joint
deformities.
Release of joint contracture by incising
the scarred tissue
A contracted joint is freed by making an incision in the scar
across the joint surface. The incision is placed in line with
the axis of joint rotation. The incision is confined within the
width of the scar initially and is lengthened as necessary to
achieve the intended release. Prior infiltration of the area
with lidocaine containing epinephrine in 1 : 400 000 concen­
tration is useful in obtaining hemostasis and later pain
control. The incision, however, must be made with caution
to avoid injuring major vessels and nerves. This is achieved
by ‘pushing’ instead of ‘slicing’ motion of a surgical blade to
free the scarred tissues. The extent of release is assessed by
the improvement of joint motion gained as the scarred tissue
is severed.
In rare instances, cicatricial changes could involve the joint
capsule. Reconstruction of the capsular structure will be
necessary.
The z-plasty technique
A contracted area can be lengthened by use of the z-plasty
technique.9 The technique utilizes the principle that a con­
tracted wound is lengthened by interposing two triangular
skin flaps mobilized from an unburned area immediately
adjacent to the area of release. The lengthening of the wound
is maximally attained by interposing two triangular flaps of
60° angle. While the z-plasty technique is an excellent means
to ameliorate the problem of wound contracture; it is not
possible if the amount of uninjured skin adjacent to the
wound is limited.
Wound coverage
There are six basic techniques of wound coverage. Namely:
1. Primary closure of the wound
2. A full-thickness or partial-thickness skin graft
3. An interposition skin flap mobilized from the area
adjacent
4. Combination of an interposition skin flap and skin
grafting
5. A muscle or skin-muscle flap mobilized from the adjacent
area
6. A free skin or skin-muscle flap harvested from a distant
site and transferred via a microsurgical technique.
Primary closure of the wound
Wound closure per primum following burn scar excision is
difficult if not entirely impossible. Inelasticity of the skin
surrounding the wound and an inadequate amount of unin­
jured skin available for mobilization and closure preclude
the use of this method of wound closure. Closure of a result­
ant wound following release, in practice, would defeat the
original objective of contractural reconstruction.
Skin grafting technique
The use of a piece of skin graft, full or partial thickness,
to cover a wound is the most fundamental technique of
wound coverage that is technically simple with minimal
morbidities.
Operative technique
A partial-thickness skin graft of 15/1000th to 20/1000th in
thickness is harvested from an unburned area using a der­
matome. The scalp, lower abdomen, and the anterior surface
of the upper thigh are the common donor sites.
A piece of full-thickness skin graft can be harvested from the
lower abdomen, above the suprapubic or inguinal area,
without leaving unsightly donor site defects. The subdermal
fatty tissues are removed but attempts should be made to
preserve the subdermal capillary plexus (Fig. 56.11). The
donor defect is usually closed primarily.
The graft is cut to fit the defect and the edges are anchored
with 3–0 silk sutures. The ends are left sufficiently long to
tie over a bolster to immobilize the graft. Several anchoring
‘mattress’ stitches using 4-0 or 5-0 chromic catgut sutures
may be placed in the center of the graft to immobilize the
skin graft against the base. Hemostasis around the recipient
site is essential. Hematoma formed underneath the graft will
hinder the ‘take’ of the graft.
After care
The bolster is usually removed in 4–5 days after the proce­
dure. Bodily fluid or blood elements accumulated under­
neath the graft, i.e. seroma and/or hematoma are evacuated.
This is achieved by making a small ‘nick’ in the graft with a
pair of surgical scissors. The fluid is ‘rolled’ out with a cotton
tip applicator. The joint is immobilized immediately and
pressure dressing is used to minimize the consequence of
contracture. Physical exercise is resumed 3 weeks after the
surgery.
An interposition flap technique
This technique, known by various names such as ‘ 34 z-plasty’
technique, a ‘banner’ flap interposition technique, etc., is the
most useful method of wound coverage following a releasing
procedure for a contracted joint. The technique is based
upon a principle that an open wound consequential to surgi­
cal release may be covered with a skin flap mobilized from
an adjacent area. While designing of a flap is technically
simple, it requires an area of unburned skin adjacent to the
released wound.
Operative technique
A triangular skin flap is designed in an unburned area adja­
cent to the wound following release. A vertical limb of the
flap begun at the end of released wound edge is set at a 90°
angle to the end of the wound. The limb length is equal to

Management of contractural deformities involving the shoulder (axilla), elbow, hip and knee joints in burned patients
639
The use of a free flap or muscle flap
Although most of the major joint deformities could be
reconstructed with the techniques described, the use of
microsurgical technique may be occasionally necessary to
transfer a segment of soft tissue from a distant donor site.
Of the varieties of flap available, we prefer the use of
anterior lateral thigh (ALT) perforator flap.10,11 The vascular
supplies to the skin around the anterior section of the
upper thigh are consistent. Preparation of a flap is therefore,
technically simple. While the morbidities attributable to
flap harvest are generally minimal, the flap can be bulky;
secondary procedures to thin down a flap are often necessary
(Fig. 56.16). Instead, a muscle flap may be used. The tissue
bulkiness may be curtailed by using a piece of skin graft
(Fig. 56.17).
Summary
Contractural deformities of the shoulder (axilla), elbow, hip
and the knee joint are not uncommon sequelae of burn
injuries. Although the injury involving the limbs and the
joint structures could account for the deformities encoun­
tered, lack of proper positioning and inadequate physical
exercise while recovering from the injuries could further con­
tribute to genesis of the problems.
The use of brace, splint and pressure dressing is important
in minimizing such an undesirable consequence of burn
injuries. The treatment for an established joint deformity, on
the other hand, requires surgical release of the contracted
skin and scars. Various methods of reconstruction have been
the wound length. A triangular flap is formed but making
the width of flaps at mid-section the same as the wound
width. The flap can be based either proximally or distally
depending upon the direction of the triangular flap designed.
The flap is dissected out and is rotated 90° to cover the
defect. The flap donor defect is closed primarily. Healing of
the wound is usually uneventful (Fig. 56.12).
The width of flap may be narrow in instances where the
size of unburned skin is not enough to fabricate a triangular
skin flap sufficiently to cover the wound. The flap, in such
an instance, is anchored in the middle of the wound. The
two sides not covered by the flap are closed with a piece of
skin graft (Fig. 56.13).
After care
The wound edges are kept clean with antibiotic ointment.
Sutures may be removed in 10 days. Splinting of the joint is
resumed within 4–5 days and joint exercise in 10–14 days.
A muscle flap or skin-muscle flap technique
The technique is utilized in instances when the resultant
defect following release is so extensive that coverage of the
wound with a skin flap or a skin graft is not feasible.
While the latissimus dorsi muscle harvested either as a
muscle flap or as a musculocutaneous flap may be used to
cover the axillary defect, the soleus muscle flap or the
gastrocnemius muscle-skin flap may be used to cover the
wound around the knee joint (Fig. 56.14). A fasciocutaneous
flap may similarly be fabricated to cover a tissue defect
consequential to surgical release of a contracted joint
(Fig. 56.15).
Figure 56.11  (a) A piece of skin with subcutaneous tissues is removed from the abdomen and will be used as a full-thickness skin graft. (b) The
subcutaneous fatty tissues were sharply removed with a pair of fine scissors. The capillaries were left undisturbed. (c) A close up view to show the capillaries
that are left in the graft.
A
B
C

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Figure 56.12  (a) An interpositional skin flap technique, i.e. a modified z-plasty technique as useful in reconstructing a flexion deformity around the joint, as
seen in this 12-year-old individual who had sustained burn injuries around the right axilla. (b) An incision made across the area with maximal contraction
resulted in a large tissue gap of 12 cm × 5–6 cm. (c) A triangular skin + fascia flap was mobilized from the lateral upper chest area and was rotated 90°
posteriorward to cover the wound. (d) The donor site was closed primarily. (e) The appearance of the wound 2 years following the reconstruction.
A
B
C
D
E

Management of contractural deformities involving the shoulder (axilla), elbow, hip and knee joints in burned patients
641
Figure 56.13  (a) An interpositional skin flap technique of wound closure may be modified as in this 5-year-old girl who had sustained burns around
the right axilla that caused contracture of the axillary joint. (b) The skin defect was so extensive that it could not be covered completely with a single flap.
(c) The uninjured skin raised as a flap was transferred to the middle of the wound leaving the areas proximal and distal to the flap to be covered with skin
grafts. (d) The appearance of the wound 10 days following the surgery. (e) The appearance of the wound 10 years after the surgery. The flap placed in
the middle of the wound had increased in size because of body growth and stretching of the scar tissues.
A
B
C
D
E

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Figure 56.14  (a) Flexion of the knee was limited because of tight scars around the patella. (b) An incisional release of the tight area across the patella
provided the relief of knee contracture. However, it resulted in an open wound of 4–5 cm in size. (c) A medial segment of the soleus muscle was used to
cover the defect. (d) The appearance of the knee area three months following the procedure.
A
B
C
D
Figure 56.15  (a) A moderate degree of flexion contracture involving the right ankle of a 6-year-old boy required release. A triangularly shaped skin + fascia
flap was marked over the medial side of the lower leg. (b) A fasciocutaneous flap was fabricated and was rotated 90° anteriorly to cover a tissue defect
consequential to contractural release.
A
B

Management of contractural deformities involving the shoulder (axilla), elbow, hip and knee joints in burned patients
643
C
D
Figure 56.16  (a) An ALT perforator flap was used to reconstruct an ankle contracture deformity. (b) While wound coverage was achieved, the tissue was
noted to be bulky, requiring secondary debulking procedures.
A
B
(c) The closure of flap donor site required the use of a skin graft. Healing was uneventful. (d) The appearance of right ankle area 18
months following the surgery.
Figure 56.15, cont’d

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Figure 56.17  (a) The patient had sustained electrical burns resulting in
tissue loss over the right heel area. (b) The wound debridement resulted in
a large soft tissue deficit exposing the Achilles tendon. A muscle flap was
transferred via microsurgical means to cover the wound. The muscle was
covered with a piece of skin graft. (c) Healing was uneventful.
A
B
C
described to manage the problems encountered. Attempts
have been made to outline the approach of managing con­
tractural deformities involving the shoulder (axilla), elbow,
hip and the knee joints.
Further reading
Huang TT, Blackwell SJ, Lewis SR. Ten years of experience in
managing patients with burn contractures of axilla, elbow, wrist,
and knee joints. Plast Reconstr Surg. 1978;61:70-76.
Kuo YJ. Experience of ALT flap. Ann Plast Surg. 2002;48:161-166.
Larson DL, Abston S, Evans EB, et al. Contractures and scar formation
in the burn patient. Clin Plast Surg. 1974;1:653-666.
Larson DL, Evans EB, Abston S, et al. Techniques for decreasing scar
formation and scar contractures in the burn patient. J Trauma.
1971;11:807-823.
Linaris HA, Larson DL, Willis-Galstaum BA. Historical notes on the
use of pressure in the treatment of hypertrophic scars or keloids.
Burns. 1993;19:17-21.
Access the complete reference list online at

Management of contractural deformities involving the shoulder (axilla), elbow, hip and knee joints in burned patients
644.e1
© Copyright 2012 Elsevier, Inc. All rights reserved.
References
1. Cronin TD. Successful corrections of extensive scar contractures
of the neck using split thickness skin grafts. In: Trans First
International Congress on Plastic Surgery. Baltimore: Williams &
Wilkins; 1957:123.
2. Willis B. The use of orthoplast isoprene in the treatment of the
acutely burned child. A follow-up. Am J Occup Ther. 1970;24:187-
191.
3. Larson DL, Evans EB, Abston S, et al. Techniques for decreasing
scar formation and scar contractures in the burn patient.
J Trauma. 1971;11:807-823.
4. Larson DL, Abston S, Evans EB, et al. Contractures and scar
formation in the burn patient. Clin Plast Surg. 1974;1:653-666.
5. Larson D, Huang T, Linaris, H, et al. Prevention and treatment of
scar contracture. In: Artz CP, Moncrief JA, Pruitt BA, eds. Burns.
A team approach. Philadelphia: WB Saunders; 1979:466.
6. Huang TT, Blackwell SJ, Lewis SR. Ten years of experience in
managing patients with burn contractures of axilla, elbow, wrist,
and knee joints. Plast Reconstr Surg. 1978;61:70-76.
7. Bauer PS, Larson DL, Stacy TR. The observation of myofibroblasts
in hypertrophic scar. Surg Gynec Obst. 1975;141:22-26.
8. Linaris HA, Larson DL, Willis-Galstaum BA. Historical notes on
the use of pressure in the treatment of hypertrophic scars or
keloids. Burns. 1993;19:17-21.
9. McCarthy JG. Introduction to plastic surgery. In: McCarthy JG, ed.
Plastic surgery. Philadelphia: WB Saunders; 1990:55.
10. Kuo YJ. Experience of ALT flap. Ann Plast Surg. 2002;48:161-166.
11. Mardini S, Tsai FC, Yang JY. Double free flaps harvested from one
or two donor sites for one or two-staged burn reconstruction:
models of sequential-link and independent-link
microanastomoses. Burns. 2004;30:729-738.

Care of a burned hand and
reconstruction of the deformities
Xin Chen, Ted Huang, Nora Nugent, Yuming Shen, Fengjiun Qin
Introduction
The human hand is not only an organ to handle tools but
also the apparatus to express emotion. Although it accounts
for only 2.5–3% of the total body surface area, a hand can
become involved in up to 80% of the treated burn injuries.1,2
A hand may be burned as an isolated injury, or in conjunc­
tion with other body areas. It is rarely spared from injuries
if burns involved >60% TBSA. Hand burns occur more fre­
quently at the workplace3,4 and are more likely to be flame
burns or electrical burns. Scalds, explosions or open flames
are the likely causes of injuries occurred at home and contact
burns to the hand and scald injuries are common in small
children.5
Functional recovery of an injured hand, in short, depends
upon early stable wound coverage, an adaptable skeletal
framework, movements and strength of musculotendinous
structures restored while the magnitude of original injuries
governs functional impediment6; loss of the thumb, for
instance, accounts for a 50% function loss of the whole
hand.7
Management of a burned hand
Initial assessment
The basic principle of patient evaluation and treatment for
trauma patients is followed. That is, the injuries involving the
hand are quite often a part of extensive thermal injury.2,3
Access to the information concerning the circumstances
under which the accident took place is essential in patient
management; the knowledge concerning causative agent and
the causative factors of the accident, e.g. flame, grease, chemi­
cal, water or electrical and duration of contact, is essential in
planning the course of initial treatment for the victims and
the wounds. While assessing the overall condition of a burn
victim to ascertain a resuscitation plan, i.e. gathering the
information about tetanus immunization, hand dominance,
occupation, and past and present medical illness, any first-
aid measures such as cooling and irrigation of the burned
sites are required; wounds inflicted by heat retained longer
with some agents such as hot grease, and caustic effects of
alkaline fluid, for instance, require a different approach and
care during the period soon after the accident.
Examination of the hand must include assessing the mag­
nitude of injuries. While the extent of burn depth –
superficial/partial-thickness and full-thickness – is usually
easy to distinguish, assessing a deep but superficial burn
wound can be difficult. Generally speaking, distinguishing
wounds between superficial/first degree and superficial
partial-thickness/second degree burns is much more diffi­
cult. They are usually erythematous, painful and blistered.
The wounds blanch readily with pressure. Wounds with
deeper burns may appear pallid or may be erythematous but
often mottled. The magnitude of sensory changes, however,
varies. Full-thickness/third degree burns are pale and assume
a brownish color. The wound is anesthetic and leathery
in consistency. Coagulated blood vessels may be readily
visible.2,8 Although a burn wound is classified as fourth
degree when the underlying soft tissue and/or bone are
involved, the depth classification rarely falls into such clear
categories (Fig. 57.1).
The thickness of skin and the underlying soft tissue can
vary depending upon the parts of the hand and the age of
patients; these factors often affect the magnitude of injuries.
That is, the skin over the back of the hand, for instance, is
thin, particularly in children and in the aged. Consequently,
the area is more vulnerable to deeper injuries; the area is
prone to edematous swelling and more aggressive measures
of decompression are needed during the acute phase of
injury.2,3,5
Initial care of a burned hand
Cooling the burned hand, an effective means to provide pain
relief and the possible curbing of further tissue damage, is
instituted on-site soon after the accident. The injured hand
is submerged in cool running water, if not iced, and is con­
tinued until a definitive therapy can be rendered. For chemi­
cal burns, the injured site is continuously irrigated with cool
water if not iced. It is continued until the wound surface pH
value, if the measurement is possible, returns to near neutral.
Restoration of hand function is the ultimate objective in
managing the injured hand. Treatment follows the principles
that would prevent additional tissue damage and provide
quick recovery and restoration of hand function. Delayed or
‘conservative’ burn wound treatment inevitably leads to
further wound complication as it could involve tendinous
structures as well as the underlying bony skeleton, the
©2012 Elsevier Ltd, Inc, BV
DOI: 10.1016/B978-1-4377-2786-9.00057-6
CHAPTER 57 
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dorsal to the digital neurovascular bundle that may include
the Cleland’s. A single incision is made in the radial side of
the thumb and the ulnar side for the fingers.2 Releasing inci­
sions may be extended into the web spaces to assure the
integrity of vascular supplies to the intrinsic musculatures
of the hand. Incisional releases may be carried out to involve
the forearm muscle compartment and the carpal as well as
the Guyon canals in electrical burns (Fig. 57.2).
The wounds following decompressive maneuvers are
covered with cadaveric skin graft or non-adhesive dressing
impregnated with antimicrobial ointment.2,6 Continuous
elevation of the injured limb is important to curtail
features which could indicate a poor prognosis for the
victims. Surgical intervention is contemplated in all hand
burns unless the magnitude of injuries are obviously and
definitely superficial.
Escharotomies are carried out either at bed side using an
electrical cautery or a cold knife once the vascular status of
the involved limb is judged to be compromised. Incisions
are made over the medial and the lateral mid-axial lines
through the skin down to the muscle layers. The line of
release extends both caudad and cephalad beyond the
margin of tissue swelling to assure complete release. The
incisions on fingers are made along the mid-lateral line just
Figure 57.1  (a) A hand that has sustained
superficial burns. (b) Pallor mixed with
erythematous changes, i.e. mottling, noted in a
hand that has sustained flame burns. (c) Findings
of skin anesthesia and vessel thrombosis suggest
full-thickness skin injuries. (d) Carbonization
suggests a complete destruction of the structures.
A
B
C
D

Care of a burned hand and reconstruction of the deformities
647
wound coverage. The resultant wound, with fully vascular­
ized dermal template in place, is covered with a partial-
thickness skin graft.9 Similarly, Aldoderm®, an inert cadaveric
dermis, may be used.6
The depth of burn wound that involves the palm, in most
instances, is superficial, as it is protected by the thick epider­
mal layer of the palmar skin. The recovery is consequently
much quicker and less eventful in comparison with an open
wound of the dorsum of the hand. A conservative regimen
of treatment when and if used to manage an open wound
involving the dorsum of the hand results in a much longer
time to heal than an injury that involves the palmar surface.
The use of full-thickness skin grafting appears to provide
excellent results but may be limited to wounds of a small
area.10 On the other hand, the efficacy of FTSG as reported
by others, could not be ascertained.11,12
Finger joints, especially over the dorsum, tend to become
exposed because of thinness of the skin and high vulnerabil­
ity to injury. In order to minimize boutonnière deformities,
the DIP and PIP joints are maintained at full extension with
the Kirschner wires placed intramedullarily for a period of
time.2 The use of skin flaps will be necessary in instances
where the joint, the tendinous as well as neurovascular
structures become completely devoid of soft tissues, cover­
age. The results with the use of skin flap, especially mobi­
lized from a distant site, on the other hand, are not entirely
satisfactory because of the thickness of skin over the joint
structures.2,6
After care
The care of a burned hand soon after the treatment consists
of hand elevation to minimize tissue swelling and pain.2
Persistent edematous swelling of the hand is believed to
result in a loss of joint mobility and dorsal skin laxity impair­
ing joint movements, especially at the metatarsophalangeal
(MTP) joints level. A protective splint that will maintain
MCP joint flexed at 70° and the PIP, as well as DIP joints
kept at full extension, with the hand in a position of ‘safety’,
is used (Fig. 57.3). Otherwise, a contracted palm, stiff and
edematous changes. The wounds are managed during the
following 10–14 days by performing additional wound deb­
ridement if indicated, and wound closure by means of skin
grafting and/or skin flap techniques.
Definitive surgical care of burned hand wound
Any wounds judged to be unequivocally third-degree burns,
or those showing no progressive signs of healing, require
surgical intervention. The procedure may be delayed for
victims with extensive injuries; surgical care of other vital
sites takes place ahead of the hand wound coverage, even
though such a delay in caring for hand wounds often results
in deformities caused by thickening of the scar and contrac­
tion of the joints. Diligent exercise and physiotherapy could
minimize the undesirable consequences.2,3
Tangential excision of the burn wound with immediate
skin grafting of the resultant wound is the ideal approach in
managing the burned hand. The definitive procedure of
wound coverage may be delayed in instances where the exact
depth of injuries, especially in electrical injuries and crush
injuries, or the exact magnitude, could not be ascertained
with assurance. A second-look procedure is needed to assess
the wound; additional removal of devitalized tissues, in
practice, is often necessary.
The use of a sheet of skin graft, partial in thickness, is
preferred to cover an open wound of the dorsum of the hand
because of a better achievable outcome, i.e. pliable scars and
good color match. However, the use of a meshed skin graft
in 1 : 1 or 1.5 : 1 in ratio, a minimally meshed graft, has been
reported to provide a similarly good outcome.2,3,5,6 In addi­
tion, artificial dermal regeneration template materials such
as Integra®, Pelnac® and Terudermis®, may be used for initial
Figure 57.2  Release of the carpal tunnel as well as the Guyon’s canal may
be necessary.
Figure 57.3  A hand splint that will maintain the DIP-PIP joints at full
extension, MCP joints at 70° while keeping the wrist joint at 30° extension,
i.e. the hand in a position of ‘safety’.

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contracted PIP and extended DIP joints, the classic bouton­
nière’s deformity, is a common sequela noted in a hand
improperly positioned.1 A temporary pre-manufactured
splint can be placed on the patient with the initial dressing
application and continued after the initial assessment. A
customized hand splint should be used to support hand
position over 2–3 days post-injury since a pre-manufactured
splint may cause unwanted pressure points in the hand.
Removal of the splints for range of motion exercise at least
twice a day is recommended.13,15 The hand is kept in a pro­
tective posture and elevated for 4–5 days following surgical
treatment.
Although a partial-thickness skin graft is the most common
material used for wound coverage and wound resurfacing,
contraction of a graft site is common. Splinting of the hand
and fingers in a protective configuration is preferred; the
patients would assume the usual posture once the post-
surgical exercise regimen is completed.14 Pressure garments
are used often for patients soon after the wound closure to
control excess swelling and scar formation.13 Wrapping the
injured fingers with Coban is also used to control tissue
edema.
Management of established burned
hand deformities
General principles
Although the primary objective of reconstructing burned
hand deformities is to restore hand function, recurrent prob­
lems of joint contractures and stiffness can ensue, despite
early wound coverage, continuous use of hand splinting and
physiotherapy. This is particularly true if the hand injury was
not the only site of burns, when reconstructive measures are
delayed or deferred for individuals with extensive burns or
when reconstruction of structural deformities such as eyelids,
mouth and neck takes precedence over hand deformities.
The procedures may be modified because of the paucity of
donor tissues that could be used for reconstruction.16
Two years of waiting following recovery from the injury
has been the precept and the practice in hand reconstruction
followed for the past 50 years. An early reconstructive
endeavor has been advocated in recent years, especially for
those who have shown full recovery from the injury and
whose deformities are limited to the hand.2 It is important
for both the surgeon and the patient to have a clear under­
standing of therapeutic objectives, technical details and con­
sequences one may encounter while recovering from the
procedures. It is important to inform the patient of the truth
about the procedures and for the surgeon to learn if his/her
patient has a realistic expectation about the outcome of
reconstruction.
Reconstructive methods
The following are the methods used most commonly for
correcting hand deformities:
1. Primary closure of the wound: This technique is used to
close a wound resulting from the excision of scar
tissues.
2. Grafting of a wound: In instances where primary co-
aptation of wound edges is not possible because of
extensive tissue deficit, that is, primary wound closure
is not possible, a skin graft may be harvested from a
distant site to cover the wound. Skin grafts are classified
as split thickness or full-thickness. A piece of skin that
contains all layers of common integument is called a
full-thickness skin graft (FTSG), while one with only
the epidermis and the outer layer of the dermis is
termed a partial-/split-thickness skin graft (STSG). It is
said that functional and cosmetic outcome of an open
wound grafted with a piece of full-thickness skin graft
is better than one grafted with a partial-thickness skin
graft. The outcome, in practice, is not predictable.
Grafting is, furthermore, contraindicated if a wound
bed lacks vascular supplies and structures such as
tendons, bones and neurovascular bundles are devoid
of soft tissues (Fig. 57.4).
3. Skin flaps: A segment of skin with its vascular supplies
left intact in the subcutaneous layer of the skin, is
fashioned to form a pedicle. When a skin flap is
transferred to make up a tissue deficit caused by scar
excision and/or release, a resultant wound of flap
fabrication is closed in most instances primarily. In rare
occasion, a piece of skin graft is used for wound
closure.
4. Z-plasty and modified z-plasty techniques: A scarred area
with tight scar bands mostly in one direction is
released by interposing two triangular skin flaps.
A contracted scar is released and the resultant
wound is closed by two flaps mobilized from the sides
(Fig. 57.5).
5. Musculocutaneous (MC) flap and fasciocutaneous (FC)
flap: The vascular supplies to the skin are enhanced by
incorporating either the muscle or muscular fascia
underneath. The flap is mobilized to make up a defect
resulting from scar release (Fig. 57.6).
6. Other techniques of flap fabrication: There are several
techniques used to fabricate a composite skin flap
for burned hand deformity reconstruction. They
include an arterialized skin flap, an axial flap, and
distant composite skin flaps. The design of skin flap,
harvesting and transfer are technically cumbersome.
The bulkiness of tissues transferred, furthermore, often
restricts the joint movements.
Reconstruction of phalangeal deformities
Flexion contractural deformities
Flexion contracture of an involved finger and hand formed
over the joint surface is attributable to scar contraction and
aided by contraction of the hand flexor musculatures. Release
of a contracted joint may be achieved by z-plasty or by incis­
ing the contracted scar.2,8 The resultant wound is, if feasible,
repaired by utilizing an interpositional skin flap technique,
i.e. 34 -z-plasty. Skin grafting will be the option available for
wound closure if the tissue around the operative site is not
suitable for flap fabrication. On rare occasions, complete
relief of contracture may require release of tight tendinous
structures and neurovascular bundles as well as the joint
structures. The use of a distant skin flap technique, i.e. a

Care of a burned hand and reconstruction of the deformities
649
Figure 57.4  (a) The wound defects around the palmar surface and the thumb base resulted from release of the contracture. (b) A partial-thickness skin graft
of 16/1000th of an inch in thickness was used to cover the wound. The fingers were maintained at angles with K-wires. (c) The appearance of the operative
site 18 months later.
A
B
C
A
B
Figure 57.5  (a) A line drawn indicated the line
of release and fabrication of a triangular skin flap.
(b) A triangular skin flap was elevated, i.e. a
modified z-plasty.

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A
B
C
D
(c) The flap was transposed
and the wound was closed primarily. (d) The
appearance of the left hand 2 years following
release.
Figure 57.5, cont’d
Figure 57.6  (a–e) A distally-based
fasciocutaneous flap was harvested from the
radial side of the distal forearm to cover a defect
resulting from wrist flexion contracture release.
The flap donor site was covered with a piece of
partial-thickness skin graft of 14/1000th of an
inch in thickness.

Care of a burned hand and reconstruction of the deformities
651
C
D
E
F
(f) The wrist joint became
fully extended with the releasing procedures.
Figure 57.6, cont’d

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usually extend distally as well as proximally to include the
entire digit and the wrist joint surface. Although the use of
hand and finger splints could prevent the genesis of deformi­
ties, the task of splinting injured joints soon after the injury
is difficult and true efficacy is difficult to ascertain. Surgical
intervention may be necessary to correct an established
deformity (Fig. 57.8).
The contracture is released by incising the scar over the
deformed finger joint(s), i.e. the deformed DIP, PIP and the
MCP joints. Inserting a K-wire from the proximal phalanx
through the MCP joint into the metacarpal bone while the
MCP joint is flexed at 90° will maintain the PIP and DIP
joints flexed. While a transpositional skin flap, i.e. 34 -z-plasty
technique, may be used to cover the wound defect over the
finger joint defect, STSG is needed for the wound coverage
cross-finger flap technique, will be necessary to cover the
exposed tendons, digital neurovascular bundles and the
joint. The use of an axial lateral digital flap, a neurovascular
island flap, may be necessary for a finger that has lost sensory
supply to restore not only the soft tissue deficit but also the
sensory supply. The finger is maintained at full extension by
inserting an intramedullary Kirschner wire or a wire placed
underneath the flexor tendon sheath to maintain finger posi­
tion for a period of 10–14 days (Fig. 57.7).
Extension contractural deformities
An isolated extension contracture of the fingers that involved
the PIP and MCP joints is attributable to scarring formed
over the area of these joints. In practice, the deformities
Figure 57.7  (a) Palmar contracture developed
in a 7-year-old child. (b) The tissue deficit was
extensive. (c) A partial-thickness skin graft instead
of a skin flap was chosen for wound coverage
because of morbidity associated with a skin flap
technique. The digits were held extended with
the use of intramedullary K-wires. (d) The release
of the digits achieved by the palmar release.
A
B
C
D

Care of a burned hand and reconstruction of the deformities
653
ulnar side of the fingers, rotated into a contracted web space,
especially to the second, third and the fourth, to achieve the
release. No additional physiotherapy is necessary. Daily
unrestricted use of the hand will restore the web space and
the movements of the fingers (Fig. 57.9).
The first web space contracture
The first web space contracture, i.e. the widest hand web
space, between the thumb and the index finger, is similarly
quite common. While conventional techniques such as
z-plasty, skin grafting, etc. may be used to reconstruct the
deformity, the technique consisting of combining two
over the MCP joint. While a distant skin flap may appear
beneficial, its bulkiness inevitably limits the finger move­
ments necessitating secondary procedures such as excision
of fatty tissues and re-grafting or defatting maneuvers.
Web space contracture
Narrowing of the web space, i.e. cicatricial syndactyly, is a
common sequela of burn hands. Although numerous varie­
ties of techniques have been described for correction, place­
ment of unburned tissues in the dorsal aspect of the web is
the key of reconstruction. This is most easily achieved by use
of a triangular skin flap mobilized from either the radial or
A
B
C
D
E
Figure 57.8  (a) A 3-year-old child sustained burns involving 45% total body surface area that had included the hands. Contraction of the hand was mostly
over the dorsum. (b) The hand 2 years following the release. (c) The hand 3 years following the release. (d) The hand 4 years following the release. (e) The
hand 5 years following the release.

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Figure 57.9  (a) Contracture involving the right second web space. A 34-z-plasty, with its triangular skin flap donor site on the radial side of the middle finger
proximal phalanx. (b) The flap was rotated dorsally and the wound was closed primarily. (c) The appearance of the operative site 3 years following the
release. Healing was uneventful.
A
B
C
z-plasty and one central Y-to-V plasty, commonly known as
the trident flap technique, the ‘jumping-man’ technique,
seagull-wing flap technique or five-flap technique, is a simple
and effective approach in providing the release. Approxi­
mately 30–40% increase in the web space is obtainable with
this technique of release (Fig. 57.10).
Reconstruction of a deformed thumb
It is estimated that 45–50% of hand functions are lost
with the loss of a thumb.7A patient can regain the basic
hand function of pinching with partial grasping of an
object if a digital knob can be restored. Although
techniques of thumb elongation such as bone-grafting,
skeletal traction and toe-to-thumb transplantation have
been advocated, they are unsuitable for thumb replacement
in a burned hand, especially in children. Paucity of donor
sites, inelastic skin unyielding to traction, a high rate of
technical failure and the morbidities inherent in these regi­
mens are the factors that account for the difficulties noted
in practice.
Digital stacking technique of thumb
reconstruction
The technique of stacking a remnant of the second digit to
the first to elongate the thumb remnant has been in use in
Galveston for the past 30 years. The remnant of the second
digit is transected at the mid-carpal level. The distal segment
is fabricated as a composite tissue graft with its neurovas­
cular bundle kept intact. The bony end is ‘stacked’ upon the
distal end of the thumb remnant. Resection of the second
digit remnant in practice creates a deeper first web space
while elongating the thumb remnant. The procedure,
though technically cumbersome, carries low morbidities
and could be performed in an outpatient surgical facility
(Fig. 57.11).
Reconstruction of deformities involving
the dorsum of the hand
Incisional release of contracted scar tissues affecting the joint
movement and covering of the resultant wound with skin
grafting or skin flap techniques is the basic principle used
for deformity reconstruction. Freeing of the periarticular
structures of the MCP, PIP and DIP joints is sometimes nec­
essary. K-wire fixation of the released joint at 90° for a period
of 10–12 days following surgical release is necessary.
The technique of skin grafting is the most common method
used to cover an open wound resulting from scar tissue
removal or contractural release. A distant skin flap may
appear to circumvent the undesirable sequelae of skin graft­
ing technique, i.e. scar hypertrophy and scar contracture, but
the bulkiness of tissues used inevitably interferes with finger
and hand motion. Repeated procedures are usually needed
to thin down flaps to gain joint mobility.
Electrical injuries involving the upper limb
The exact mode of tissue injuries caused by electricity remains
incompletely understood. Although cell damage directly
caused by electrical current may account for some of the

Care of a burned hand and reconstruction of the deformities
655
the major culprit responsible for muscle and neurovascular
bundle destruction. Electrical burns of the upper extremity,
unlike other thermal injuries, are deep third-degree burns if
not a ‘fourth’-degree injury. The regimen for electrical burns
of the upper extremity and the outcome of treatment differ
from thermal injuries involving other organs.
The classification of upper limb electrical burns
The gross appearance of the injured site, the operative find­
ings, the magnitude of tissue damage, and the location of
electrical contact play an important role in governing
the healing processes and the outcome of treatment ren­
dered. The wounds are classified into four categories: the
location of injuries; the magnitude of arm involvement;
the magnitude of impairment and the involvement of
injuries noted, most of the tissue damage is believed to be
due to heat generated by electrical current flowing through
the tissues with extreme resistance; it follows Ohm’s Law and
Joule’s Law of electricity, respectively, i.e. Current (I) =
Voltage (E) ÷ Resistance (R); Power (J) = (Current) I2 × Resist­
ance (R).
The upper limb is a common site of injuries sustained at
work sites for adults and while playing in areas with high
voltage electrical lines for children. Although the precise
mode of injuries is unclear, the affected area often includes
the entire extremity, i.e. the shoulder to the hand. The
damaged structures noted are mostly the muscles in the arm,
neurovascular bundles, and the skin over a contact point in
the forearm and in the hand. The magnitude of structural
damage observed is believed to be related to the long bones.
The heat generated in the bone with the flow of electricity is
Figure 57.10  (a) A moderate degree of web space contraction developed in the first web space 9 months following the accident. Skin markings were
for a trident technique of contracture release, alias a 5-flaps release technique, a jumping-man releasing technique. (b) A trident technique is composed
of z-plasties and Y-to-V releasing technique. (c) An increase of 30–50% in arc length with the multi-flap technique. (d) The appearance of released web space
3 years later.
A
B
C
D

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both median and ulnar nerve sensory impediment; gross
circulatory impairment to the hand; rapid wound deteriora­
tion (Fig. 57.12c).
Type IV: A wound with circumferential arm involvement
with accompanied hand involvement; hand vascular circula­
tion is nil (Fig. 57.12d).
Diagnosis of arterial injuries secondary to
upper limb electrical injuries
The probability of tissue necrosis caused by high voltage
electricity soon after the accident may vary between 10% and
60%. The incidence of extremity amputation among those
diagnosed to have a Type III injury can be in the range 25–
80%, attributable to vascular injuries. Assessing and delin­
eation of vascular injuries for patients with electrical burns
neurovascular structures are the key features used for the
classification.
Type I: A wound which involves the superficial digital
flexor musculatures but spares the deep digital flexors, with
minimal or no ulnar nerve impediment, and a grossly
normal vascular supply to the hand (Fig. 57.12a).
Type II: A wound which involves the entire flexor surface
but a portion of the lateral side of the forearm; extensive
but moderate damage involving the superficial and deep
digital flexor musculatures respectively; pronator muscle
damage; no or minimal median nerve injury but a moderate
degree of ulnar neurosensory impediment; variable circula­
tory disturbances but improving with wound decompression
(Fig. 57.12b).
Type III: A wound with circumferential burns; gross impair­
ment of both superficial and deep flexor musculatures; loss
of pronator musculature movement; a moderate degree of
A
B
C
D
E
Figure 57.11  (a,b) The skin drawing marked the skin edges of index finger remnant. (c,d) The index finger remnant was fabricated as a composite island
flap containing bony skeleton and the neurovascular bundles. The island flap was transferred to the remnant of the thumb. K-wires were used to anchor the
graft. (e) The thumb remnant was lengthened by stacking the index finger remnant. The web space was deepened by removing the second metacarpus.

Care of a burned hand and reconstruction of the deformities
657
Decompressive escharotomy and fasciotomy
Tissue destruction that particularly involves deep structures
inevitably leads to interstitial extravasation of tissue fluid
and the consequences of tissue swelling. Decompression of
tight tissue compartment by incising the skin tightened
because of burns and/or loss of elasticity is essential to
restore both arterial and venous flow. The release of muscle
compartments is furthermore, necessary in instances where
the muscle compartments are swollen. Without releasing
procedures, ischemia can cause the demise of other struc­
tures such as nerves. Necrotic muscles should be removed as
soon as possible to prevent systemic toxicity.
Early debridement
It is appropriate for patients whose general condition is
stable and without obvious limb vascular impediment to
undergo wound debridement procedures from 1–2 days fol­
lowing injury. The procedures should include removal of all
devitalized tissues, ascertaining the viability of digital mus­
culatures, pronator and supinator muscles. All efforts are
made to preserve all forearm nerve structures, unless nerve
viability is clearly lost. Vascular continuity, in instances
are, therefore, extremely important at the time of initial
evaluation.
The structural and functional integrity of the arterial trees
are assessed and the following tests are useful:
•
Circulatory disturbance in the hand: note skin
discoloration, cyanosis, coolness and delayed capillary
refill
•
Gross appearance of the wound depth: vascular
thrombosis and/or disruption
•
Vascular patency assessed by means of palpation or
Doppler flowmetry
•
Allen’s test
•
Colorimetric studies
•
MRI
•
Arteriography
•
Surgical exploration.
The management of limb electrical burns
Patients sustaining electrical burns of the upper limb are not
infrequently found to suffer other injuries. Surgical debride­
ment of burn wounds is planned once the condition of the
burn victims is stabilized.
Figure 57.12  (a) Type I electrical burn injuries of the hand-forearm. (b) Type II electrical burn injuries of the hand-forearm. (c) Type III electrical burn injuries
of the hand-forearm. (d) Type IV electrical burn injuries of the hand-forearm.
A
B
C
D

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where the patency of both radial and ulnar arteries is com­
promised, may be restored by means of a vein-grafting tech­
nique. The use of anticoagulants, i.e. low molecular Dextran
or heparin, will be necessary for a period of time to mini­
mize the recurrence of vascular thrombosis.
Wound management
The magnitude of tissue damage in high voltage electrical
burns is often so extensive that it involves muscles and blood
vessels. Limb removal, in such instances, is the sole treat­
ment option left in order to minimize lethal consequences
of the injuries. The conventional regimen of a split-thickness
skin graft for wound coverage is generally not feasible
because of wound beds devoid of vascular supplies and/or
tissue loss (Fig. 57.13). Instead, a skin flap mobilized from
an area adjacent or distant is used for not only the wound
coverage but also for nurturing the nerves. Because of the
injuries, an axial skin flap fabricated in the forearm, i.e. a
radial forearm flap, abdominal flap, musculocutaneous flap,
or free flap/perforator flap transferred via microsurgical
means, is preferred (Fig. 57.14).
Functional reconstruction of limb deformities
Loss of limb function is not uncommon following electri­
cal injuries. Insufficient vascular supply, extensive nerve
and musculotendinous damages, loss of muscle functions
involving the shoulder girdle and the forearm, as well as
loss of intrinsic musculatures of the hand are the factors
responsible for the difficulties encountered.
Maintaining joint mobility and replacement of lost soft
tissue in the forearm and the hand are two key features nec­
essary for functional reconstruction. Patients are encouraged
to follow a physical exercise regimen to maintain joint
mobility, particularly of the finger joints. Successful nerve
grafting for sensory restoration and/or tendon transferring
procedures for digital movements requires prior skin flap
procedures mobilized from an adjacent area or a free flap
transferred via microsurgical means to restore the soft tissue
coverage of the injured site. Restoration of the tendon activi­
ties is contemplated once these procedures are completed.
The rehabilitative regimen in general takes minimally 2–3
years to complete.
Comments
Effective hand reconstructive procedures rely not only on the
surgeon’s surgical judgment and skill but also on patients’
compliance with rehabilitative treatment following the oper­
ation. Although sensitivity to the needs of patients with
burned hand deformity is not infrequently overlooked in the
presence of other problems, the support for this group of
patients cannot be minimized. Care for injured hands must
be instituted as soon as possible and should continue for a
Figure 57.13  (a,b) Once the wounds are judged to be ‘clean’, a skin flap mobilized locally or from a distant site is used to cover the wound. An 18-year-old
man sustained high-voltage electrical injury. The exit wound located in the forearm was covered with a flap mobilized from the lower abdomen. (c) An
elbow wound was covered with a local skin flap.
A
B
C

Care of a burned hand and reconstruction of the deformities
659
Further reading
Dantzeer E, Queruel P, Salinier L, et al. Dermal regeneration template
for deep hand burns: clinical utility for both early grafting and
reconstructive surgery. Br J Plast Surg. 2003;56:764-774.
Greenbalgh DG. Management of acute burn injuries of the upper
extremity in the pediatric populations. Hand Clin. 2000;16(2):
175-186.
Luce EA. The acute and subacute management of the burned hand.
Clin Plast Surg. 2000;27(1):49-63.
Pensler JM, Steward R, Lewis SR, et al. Reconstruction of the burned
palm: full-thickness versus split thickness skin grafts – long term
follow up. Plast Reconstr Surg. 1988;61(1):46-49.
Tredget EE. Management of the acutely burned upper extremity. Hand
Clin. 2000;16(2):187-203.
long period of time. The task of reconstructing a deformed
hand if its needs are neglected during the initial phase of
injury treatment is quite difficult. The preparation of an
injured patient for his/her return to society can be hampered
by delay in restoring hand deformities and functions. A well-
planned regimen is essential for an early restoration of these
individuals to their former lives.
Summary
Reconstruction of a burned hand deformity begins with care
at the time of hospital admission. Early surgical attention,
with control of edema and proper hand positioning is essen­
tial for a satisfactory outcome of treatment. A satisfactory
outcome is, however, is governed by a treatment plan organ­
ized with inputs from all people concerned. A team approach
is essential for handling the problems of the burned hand.
Figure 57.14  (a-c) A composite skin flap, i.e. an ALT flap, harvested from the
anterior thigh area, may be used via microsurgical means to cover an
extensive wound.
A
B
C
 
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Care of a burned hand and reconstruction of the deformities
659.e1
© Copyright 2012 Elsevier, Inc. All rights reserved.
References
1. Luce EA. The acute and subacute management of the burned
hand. Clin Plast Surg. 2000;27(1):49-63.
2. Smith MA, Munster AM, Spence RJ. Burns of the hand and upper
limb – a review. Burns. 1998;24:493-505.
3. Tredget EE. Management of the acutely burned upper extremity.
Hand Clin. 2000;16(2):187-203.
4. Baack BR, Osler T, Nachbar J, et al. Steam press burns of the
hand. Ann Plast Surg. 1993;30:345-349.
5. Greenbalgh DG. Management of acute burn injuries of the upper
extremity in the pediatric populations. Hand Clin 2000;16(2):
175-186.
6. Heimbach DM, Logsetty D. Modern techniques for wound
coverage of the thermally injured upper extremity. Hand Clin.
2000;16(2): 205-216.
7. Kurtzman LC, Stern PJ, Yakuboff KP. Reconstruction of the burned
thumb. Hand Clin. 1992;8(1):107-119.
8. Belliappa PP, McCabe SJ. The burned hand. Hand Clin.
1993;9(2):313-324.
9. Dantzeer E, Queruel P, Salinier L, et al. Dermal regeneration
template for deep hand burns: clinical utility for both early
grafting and reconstructive surgery. Br J Plast Surg. 2003;56:
764-774.
10. Pham TN, Hanley C, Palmieri T, et al. Results of early excision
and full-thickness grafting of deep palm burns in children. J Burn
Care Rehabil. 2001;22:54-57.
11. Pensler JM, Steward R, Lewis SR, et al. Reconstruction of
the burned palm: full-thickness versus split thickness skin
grafts – long term follow up. Plast Reconstr Surg. 1988;61(1):
46-49.
12. Wu LC, Gottlieb LJ. Glabrous skin grafting: a 12-year
experience with the functional and aesthetic restoration of
palmar and plantar skin defects. Plast Reconstr Surg.
2005;116:1679-1685.
13. Leman CJ. Splints and accessories following burn reconstruction.
Clin Plast Surg. 1992;19(3):721-731.
14. Burm JS, Chung CH, Oh SJ. Fist position for skin grafting on the
dorsal hand: I. Analysis of length of the dorsal hand surface in
various positions. Plast Reconstr Surg. 1999;104:1350-1355.
15. Harrison DH, Parkhouse N. Experience with upper extremity
burns. The Mount Vernon experience. Hand Clin. 1990;6(2):
121-209.
16. Salisbury RE. Reconstruction of the burned hand. Clin Plast Surg.
2000;27(1):65-69.

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Management of burn injuries
of the perineum
Ted Huang
Introduction
Burns of the perineal area are quite uncommon even though
the lower trunk and the lower extremities are vulnerable to
burn injury. Alghanem et al. reported the incidence of peri­
neal burns to be about 12/1000 admissions, more than 20
years ago.1 While the occurrence of perineal burns has
remained fairly consistent at 1.0–1.5% at our hospital, 35
children underwent genito-perineal reconstruction, out of
1133 presentations between 2002 and 2009. An increase in
the number of children who have survived extensive burns
of a total body surface area (TBSA) involvement of more
than 40%, could account for the increase in the number of
children requiring secondary reconstruction.
Management of burns of the perineum during
acute phase of injury
A conservative approach is used to manage perineal burns.1,2
The perineal area is cleansed daily and the wound is covered
with antibiotic dressing. The urethral tract is stented with an
indwelling Foley catheter as it is also used to decompress the
urinary bladder. The perineal area is neither splinted nor
braced. The thighs are maintained at 15 degrees of abduction
using a wedge splint to minimize contracture of the hip
joint. The extent of burns is allowed to demarcate in time
and the wound is often left to heal spontaneously. A non-
healing wound is managed with the use of a partial-thickness
or a full-thickness skin graft. On rare occasions, a skin flap
may be mobilized from the area adjacent to reconstruct
defects consequential to full thickness skin loss of the penis
and the scrotum.
Other possible problems seen with burns of the perineum
during the acute phase of injury, include necrosis of the
penile shaft, testicular necrosis, urethral stricture, and rectal
prolapse. Although the Shriners Burns Hospital and the
University of Texas Medical Branch Hospitals in Galveston,
Texas, have adopted a relatively conservative regimen to
manage perineal burns, the approach of wound care is in
practice, quite variable, and the exact regimen is often modi­
fied depending upon the structures involved.
Burns of the penis
Burn injuries limited to the penis, though possible, are quite
rare (Fig. 58.1). Concomitant involvement of the penis with
burn injuries of the lower trunk and the perineal area, on
the other hand, is quite common. The initial regimen of
patient management, in addition to resuscitative measures,
consists of wound care and urethral stenting. An indwelling
Foley catheter of appropriate size is inserted into the urinary
bladder to stent the urethral tract and at the same time, to
monitor the urinary output. The catheter is removed once
the swelling around the penile shaft has subsided and status
of the wound becomes delineated. No attempt is made to
debride the burned wound early. Instead, it is allowed to
demarcate and is often allowed to heal spontaneously.
Loss of skin over the penile shaft
and the scrotum
Spontaneous healing is expected in most instances with burn
injuries of the penis and scrotum, since full thickness injury
of the penile and scrotal skin is relatively uncommon. Skin
grafting, a partial thickness or a full thickness graft could be
used to cover the wound if healing is delayed (Fig. 58.2).
In rare instances, a skin flap may be needed to reconstruct
structures such as urethral tract and/or scrotal sac because of
loss of skin coverage. An inguinopudendal skin flap mobi­
lized from the inguinal crease area may be used if the use of
skin graft is judged not to be feasible.3 The use of muscle-skin
flap such as a gracilis MC flap is not recommended because
of subsequent high tissue temperature evolving in a skin flap
that may interfere with spermatogenesis.
Burn wound of labia majora
Isolated burns of the labial structures are rare. Instead, labial
burns are often associated with injuries of surrounding areas
such as abdomen and inguinal folds. As in the management
of burns of male genitalia, the injured areas are allowed to
heal spontaneously (Fig. 58.3). Distortion of the labial struc­
tures mostly due to contraction of scar tissues in the pubic
and inguinal areas is left for later reconstruction.
©2012 Elsevier Ltd, Inc, BV
DOI: 10.1016/B978-1-4377-2786-9.00058-8
CHAPTER 58 
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662
Figure 58.1  An isolated burn injury of the penis is relatively uncommon.
This was a 27-year-old man who sustained scalding burns of the penis from
accidentally spilling hot coffee onto his lap.
Figure 58.2  (a) Burns of the penis are more commonly associated with
injuries of the lower trunk and lower extremities. (b) Although skin grafting
was needed for wound closure around the perineum, the major bulk of
penile wounds healed spontaneously.
A
B
Perineal wound coverage
An isolated burn injury of the perineal area is extremely rare.
On the other hand, the area will become involved if the lower
trunk/buttock is injured. The extent of scar contracture varies
depending upon the depth of burns. While it may heal spon­
taneously with minimal scarring, contracture of the perineal
area is a common sequela, regardless of methods used to care
for the wound (Fig. 58.4). The natural inclination to keep the
thighs together and hip adducted during the recovery phase
of acute burn injuries seems to aggravate scar contraction.
Anal burns
Burns of the anus are rare, though it could become involved
because of extensive burns of the perineum. If the skin injury
around the anal opening is full-thickness, the use of a skin
flap may be necessary to minimize the consequence of stric­
ture. A skin flap mobilized from the area adjacent will be
necessary to graft the perianal area. Wound coverage with a
skin graft is technically difficult and will lead to anal stricture
because of graft contracture.
Rectal prolapse
Rectal prolapse occurs occasionally in young children with
extensive burn injuries with or without perineal involve­
ment. The exact reasons for rectal prolapse occurring in
burned infants remain unclear. Redundant rectal mucosa,
structural relationship of the rectum to other pelvic organs
such as sacrum and coccyx, urinary bladder and uterus, and
lack of muscular support provided by the pelvic muscula­
ture, anatomical features unique to infants of 1–3 years of
age could account for the incident. Sudden increase in intra-
abdominal pressure and malnutrition and constipation due
to response to the burn injuries could conceivably aggravate
the magnitude of the rectal mucosa descending through the
anal opening.4
Clinically, in addition to eversion of rectal mucosa, the
finding of edematous swelling around the buttocks and
perianal area is quite common, even though the area is
spared of burns. The onset can be quite sudden without any
obvious precipitating event. However, grunting or the
Valsalva maneuver can precipitate an eversion of the rectal
canal through the anal opening.

Management of burn injuries of the perineum
663
Figure 58.3  (a) Burn injuries involved the lower trunk and the thighs that
included the labia. While the lower abdomen and the thighs required skin
grafting, the labial injury was left to heal spontaneously. (b) The appearance
of genitalia 5 years after the injury.
A
B
Figure 58.4  (a) The patient was an 8-year-old child who sustained
third-degree burn injuries of the trunk and the lower extremities that had
also involved the penis and the scrotum. (b) The wound including the
scrotum was debrided and was grafted with a meshed partial-thickness skin
graft. (c) The changes which ensued in the genito-perineal area were
characterized with scar hypertrophy and burn scar contracture. Tight scars
which formed across the perineum interfered with thigh movement.
A
B
C
The regimen of treatment consists of rectal padding, and
daily cleansing of the perineal and perianal area. A stool
softener is added to the dietary regimen to facilitate bowel
movement. Spontaneous regression of the prolapse is likely
as the nutrition improves and tissue swelling subsides
(Fig. 58.5). Surgical intervention, though in most instances
unnecessary, is indicated if the prolapse is not readily
reducible due to anal sphincteric dysfunction and/or
intussusception.4,5
Reconstruction of established deformities
of the perineum and the perineal structures
Cicatricial contracture around the perineum is the most
common sequela of perineal burns.1,6 The magnitude of con­
tracture is, furthermore, exaggerated because of contraction
of burn scars in the inguinal crease and inferomedial gluteal
folds. Other problems, though relatively uncommon,
included complete loss of penis, anal stenosis, and intrac­
table rectal prolapse.
There are numerous methods such as the z-plasty tech­
nique, the interpositional skin flap technique, incisional
release of scarred tissues closed with local skin flap or skin
graft available to reconstruct the deformities. In practice,
the technique used to reconstruct perineal and genital
deformities varies depending upon the magnitude of
scarring around the perineum and the extent of functional
impediment encountered.
Reconstruction of penile deformity
The task of assessing the exact extent of penile deformities
can be difficult. Distortion of the penile configuration attrib­
utable to scar contracture could be due to loss of the skin or
a combination of the skin and Buck’s fascia. In addition,

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664
The skin defect resulting from incisional release of the scar
is covered with a full thickness skin graft if the Buck’s fascia
is spared of scar injury. In rare instances with injury that has
involved the Buck’s fascia, surgical release of the fascial
deformity is necessary. A dermal graft harvested from the
lower abdomen may be used to reconstruct burn fascial
defect. A skin flap mobilized from the area along the groin
crease, as an island skin pedicle flap, may be needed to cover
the skin defect.
Complete loss of the penis, though devastating, is
extremely rare (Fig. 58.6). Reconstruction of the penis is
Figure 58.5  (a) The patient was a 2-year-old girl who had sustained 65–70% total body surface burns.
(b) Prolapse of the rectum appeared 12 days after the accident. The problem was managed non-
surgically. (c) The prolapse receded spontaneously 2 months later as she recovered from the burn
injury.
A
B
C
scarring in the pubic area and/or the inguinal fold can
further exaggerate the extent of penile deformity.
Engorging the penile shaft is necessary to assess precisely
the extent of penile deformity, as the gross appearance of a
flaccid penis can be misleading. Artificial penile erection is
created under anesthesia by placing a tourniquet at the base
of the penis using a piece of 14 inch Penrose drain. Physio­
l­ogic saline solution is injected into the corpus cavernosum
in sufficient amount to induce congestion. The shaft deform­
ity attributable to skin loss and/or fascial loss will be delin­
eated once the corpus becomes engorged.

Management of burn injuries of the perineum
665
to high tissue temperatures exerted from the flap. Even
though contractural deformity is likely to recur, a skin graft
can be used to cover the defect.
Reconstruction of labial deformity
An isolated contour deformity of the labia majora is rela­
tively uncommon. On the other hand, scar contracture
occurring in the suprapubic and pubic area, as well as the
inguinal fold could distort the normal configuration of the
labia. Prior surgical release of the contracted scar tissues
around the pubic and inguinal fold areas is an essential step
in order to determine the extent of labial deformity and the
method to reconstruct the deformed labia.
To restore a contour deformity caused by skin and subcu­
taneous tissue loss, a skin flap may have to be mobilized
from the area adjacent. To reconstruct a contour deformity
due to parenchymal tissue loss, injection of free fat cells, i.e.
lipoinjection, could be useful. To inject free fat cells to
augment the labial contour, the cells are aspirated from the
lower abdomen using the inner cannula of #14 Intracath®
needle attached to a 3 cc syringe. The syringe is moved in a
‘back-and-forth’ piston-like manner. The fat cells are injected
into the labia using the same syringe but connected with a
19 gauze blunt needle.
Reconstruction of band deformity
around the perineum
Scarring and scar contracture of the perineum is a common
sequela of perineal burns, especially if it is allowed to heal
spontaneously. Although it seldom causes any difficulty at a
delayed until puberty. The delay is often necessary due to
limited soft tissues that can be harvested for genital recon­
struction soon after the accident.
There are several methods currently available to recon­
struct a neo-phallus. A segment of rectus abdominis MC
flap, for instance, may be mobilized from the lower
abdomen to form a neo-phallus. Although the appearance
of a reconstructed phallus may be cosmetically acceptable,
the structure usually lacks sensation; it serves as a urinary
conduit at best. More recently, a technique described by
the late Dr Kenji Sasaki of Nihon University in Tokyo,
Japan, utilizing a forearm osteocutaneous flap transferred
to the pubic area via microsurgical technique, has been
found to be useful in reconstructing a phallus. While the
urethral tract was reconstructed utilizing a piece of full
thickness skin graft or utilizing a tube-within-a-tube tech­
nique at the time of phallus reconstruction in a forearm
osteocutaneous flap technique, the pulp of a big toe was
used to reconstruct a glans penis; it provided a structural
contour resembling the glans. Coaptation of the digital nerve
to the penile nerve restores the sensual sensory mechanisms
(Fig. 58.7).7
Reconstruction of scrotal deformities
Full thickness burn injuries of the scrotum often result in
scar encasement of testicular structures. Reconstruction
requires surgical release of the scarred areas. A thin skin flap
such as the inguinopudendal flap or a flap mobilized from
the area adjacent is needed to cover the resultant defect. A
musculocutaneous flap such as a gracilis MC flap is not suit­
able for scrotal reconstruction because of the thickness of the
flap and possible impeding decrease in spermatogenesis due
Figure 58.6  (a) A full thickness burn of the penis, though uncommon, can occur and the outcome is devastating, as seen in this 10-year-old boy. No
attempt was made to remove the penile tissue, even though it appeared grossly necrotic. Instead, the wound was allowed to demarcate itself. An indwelling
Foley catheter was used to stent the urethra. (b) The patient had lost the phallus entirely. (c) The patient is able to urinate through a short remnant of the
penis. Reconstruction of the penile shaft is being planned.
A
B
C

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666
spreading of the buttock and is responsible for discomfort
with sitting.
Although a contracted perineal band may be incised to
gain release, the task of closing the resultant wound can be
difficult. Recurrence of contracture is a common sequela
with the use of skin graft. Instead, a multiple z-plasty
technique is a preferred method of reconstruction to release
scar bands around the perineum.
young age, the scars around the perineum could eventually
interfere with sitting because of tightness or contraction
around the buttock. In addition, the patient may encounter
difficulty with bowel movement because of gluteal contrac­
ture and cicatricial changes involving the anal opening.
The deformity resulting in the perineal area is usually
a tight band developed in the suprapubic area, or between
the ischial tuberosities. Inelastic scars cause inadequate
A
B
C
D
E
Figure 58.7  (a) There are various techniques available to reconstruct a penile shaft. A forearm composite flap, one of the methods currently in use, was
chosen to reconstruct a phallus structure for a 51-year-old man who lost his penis because of cancer. (b) As shown in a schematic drawing, a section of the
skin with radial artery attached is harvested from the volar surface of the forearm was utilized for penile reconstruction. A tube-inside-the-tube was used to
reconstruct the urethral tract. In addition, the pulp from the big toe was also used to reconstruct the glans penis. (c) The tissues were assembled with vessels
and nerve structures set for ‘hook up’. (d) The appearance of genitalia before reconstruction. (e) The appearance of reconstructed penis in a 50-year-old man
who had lost the penis because of cancer. (a,b,e Courtesy of Dr Kenji Sasaki. Penile reconstruction: combined use of an innervated forearm osteocutaneous flap and big toe pulp.
Plast Reconstr Surg 1998; 104:1054–1058 and reprinted with permission.)

Management of burn injuries of the perineum
667
Figure 58.8  (a) A tight scar band in the perineal area consequential to burn injuries involving the perineum and the lower extremities. (b) Releasing
incisions were placed in the areas away from the anal opening to avoid injuring the anal sphincter. A triangular flap was designed in the uninjured area at
each end of the scar band. A releasing incision was set perpendicularly to the direction of the scar band. (c) Each triangular flap was rotated 90° to close the
open wound resulting from incisional release. (d) Tight bands develop in the perineal area.
A
B
C
D
The technique of multiple z-plasty
The patient is placed in a lithotomy position. Tightness and
scar band can be delineated with abduction of the hip joint
(Fig. 58.8a). A line is drawn in the scar band along the hori­
zontal direction of the band. The length of the horizontal
line may extend from one side of the scarred area to the
other. A triangular flap with its apex at the end of horizontal
line is marked. The angle may vary between 30° and 60°
depending upon the uninjured tissues available at both ends
of the horizontal line. The length of the limb of each triangle
will be the same as the incision made perpendicular to the
horizontal line to release the tight band (Fig. 58.8b). Two
z-plasties, i.e. two triangular flaps with 30–60° and 90°
angle, respectively, are formed as the flaps are raised along
the skin markings made. Release of a contracted scar band
is achieved by rotating these two flaps at each end (Fig.
58.8c). The release of a tight band across the perineal area
was maintained by interposing a segment of soft tissues
mobilized. Figure 58.8d shows the appearance of a peri­
neum 4 years following the releasing procedure.
Although the extent of perineal release may be limited
because of scarred tissues surrounding the triangular flaps
fashioned, the z-plasty technique is useful in changing the
pulling direction of scar tissue, thus diminishing tightness
around the perineum.
Reconstruction of anal stricture
While burn injuries rarely involve the entire anorectal canal,
it is not unusual to involve the perianal skin and the external
sphincter ani muscle. Stricture of the anal opening due to
scar contracture and the cicatricial involvement of the exter­
nal sphincter ani muscle are common sequelae. Cicatricial
changes around the anal opening can and will interfere with
bowel movement.
The treatment requires surgical release of constricted scar
bands around the anal opening. An interpositional skin flap
fashioned as an island flap or a modified z-plasty with skin
flaps mobilized from the area adjacent, is used to make up
the tissue defect (Fig. 58.9). The method of using a piece of
skin graft to reconstruct the defect is not useful. Application
of the graft is difficult and recurrence of stricture is common
because of scar contracture.
Reconstruction of rectal prolapse
Although the problem, in most instances, is self-limiting and
the prolapse will recede spontaneously as nutritional status
of the patient and healing of the burned perineum improves,
surgical intervention will be necessary if the rectal prolapse
becomes intractable (Fig. 58.10).4,5

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Figure 58.9  (a) A 4-year-old boy developed, in addition to a tight scar band across the perineum, anal incontinence because of cicatricial changes that had
involved the entire perineal area. (b) A modified multiple z-plasty technique was utilized to reconstruct perineal contracture and anal stenosis. (c) Skin flaps
were rotated into the areas to reconstruct the deformity following the surgical release. (d) The appearance of the anal area before release. (e) The appearance
of the anal area 9 months following release.
A
B
C
D
E

Management of burn injuries of the perineum
669
Figure 58.10  (a) A 2-year-old boy who had
sustained a third-degree scalding burn that
mostly involved the lower extremities. He
developed rectal prolapse 10 days after the
accident. (b) He underwent a rectopexy
procedure because of persistent eversion of the
rectal mucosa. (c) The patient regained anal
continence 6 months after the surgery.
A
B
C
Summary
Burn injuries of the perineum are relatively uncommon. The
regimen of treatment during the acute phase of recovery is
conservative. The urethral tract is stented with an indwelling
Foley catheter and the wound is cleaned daily. Neither a
splint nor a brace is used to immobilize the perineal area.
The wound is usually left to heal spontaneously. The result­
ant deformity, with rare exception of total loss of the penis,
is limited. Instead, disfigurement of the scrota/labial contour
and/or scar bands around the genitalia are the common
complaints presented by the patients.
The approach in reconstructing scarred deformities is cen­
tered upon release of tight scar bands around the perineal
structures as it interferes with sitting and/or bowel move­
ment. Incisional release and reconstruction utilizing a
z-plasty technique or an interpositional skin flap technique
is effective in correcting the deformities.
Further reading
Alghanem AA, McCauley RL, Robson RC, et al. Management of
pediatric perineal and genital burns: Twenty-year review.
J Burn Care Rehabil. 1990;11:308-311.
Ashcraft KW, Garred JL, Holder TM, et al. Rectal prolapse: 17-year
experience with the posterior repair and suspension. J Pediatr Surg.
1990;25(9):992-995.
Huang T. Twenty years of experience in managing gender dysphoric
patients: I. Surgical management of male transsexuals.
Plast Reconstr Surg. 1995;96:921-930.
Sasaki K, Nozaki M, Morioka K, et al. Penile reconstruction:
Combined use of an innervated forearm osteocutaneous flap and
big toe pulp. Plast Reconstr Surg. 1998;104:1054-1058.
 
Access the complete reference list online at

Management of burn injuries of the perineum
669.e1
© Copyright 2012 Elsevier, Inc. All rights reserved.
References
1. Alghanem AA, McCauley RL, Robson RC, et al. Management of
pediatric perineal and genital burns: Twenty-year review.
J Burn Care Rehabil. 1990;11:308-311.
2. Rutan RL. Management of perineal and genital burns. JET Nurs.
1993;20:169-176.
3. Huang T. Twenty years of experience in managing gender dysphoric
patients: I. Surgical management of male transsexuals.
Plast Reconstr Surg. 1995;96:921-930.
4. Stafford PW. Other disorders of the anus and rectum, anorectal
function. In: O’Neill JA, Rowe MI, Grosfeld JL, et al., eds. Pediatric
surgery. 5th ed. St Louis, MO: Mosby; 1998.
5. Ashcraft KW, Garred JL, Holder TM, et al. Rectal prolapse: 17-year
experience with the posterior repair and suspension. J Pediatr Surg.
1990;25(9):992-995.
6. Pisarski GP, Greenhalgh DG, Warden GD. The management of
perineal contractures in children with burns. J Burn Care Rehabil.
1994;15:256-259.
7. Sasaki K, Nozaki M, Morioka K, et al. Penile reconstruction:
combined use of an innervated forearm osteocutaneous flap and
big toe pulp. Plast Reconstr Surg. 1998;104:1054-1058.

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Reconstruction of burn deformities
of the lower extremity
Jui-Yung Yang, Ted Huang
Introduction
Although the exact incidence remains undefined, the likeli­
hood of lower extremity burns is strictly related to the mag­
nitude of injury. The management of lower limb burns is
essentially identical to the regimen used for other bodily
sites. That is, the principle of debridement and wound cover­
age is followed.
Individuals with complete wound coverage may have sur­
vived the injury. True survivors are, however, those who can
ambulate at the time of discharge, as burn victims’ successful
re-entry to the society is enhanced by the success in restoring
limb configuration to regain walking posture, and efforts are
aimed to restore weight bearing and joint movement.
Reconstruction of knee, ankle
and foot deformities
General principles
Releasing contracted joints to restore the usefulness of the
foot is the fundamental approach in reconstruction. The
resultant tissue defect is covered with skin grafts and/or skin
flaps. A Kirschner’s wire of 0.025–0.035 inch in size for small
joints and a Steinmann pin of 0.045 inch or larger caliber
for a large joint is used for joint immobilization and struc­
tural alignment. The position of released joint structures is
maintained for a period of 10–14 days. The pins and wires
are removed and external appliances or shoes are used to
maintain the foot position. The techniques of skin grafting
and/or skin flap wound coverage may be plagued with prob­
lems of graft and flap loss.
Scar deformities involving the knee joint,
dorsum of the foot and the ankle
Hypertrophic scar deformities
In addition to unsightliness, thickened scars can limit joint
movements. While symptomatic and unsightly scars can be
partially or completely removed surgically, non-surgical regi­
mens designed to provide proper joint alignment may be
attained with the use of splinting and scar compression; a
knee splint and a high-top shoe, for example, are the most
common tools used.
Contractural deformities involving the toes
An extension deformity of the toes at the metatarsophalan­
geal (MTP) joint level with or without associated dorsiflex­
ion contracture of the ankle is common if the dorsum of the
foot and the ankle are involved.
Reconstruction of the dorsally contracted toes
Contracted toes are released by incising the scar at the level
of metatarsophalangeal (MTP) joint and/or proximal inter­
phalangeal (PIP) joint. Release of the scar tissues at the web
space is usually delayed to minimize morbidities associated
with aberrant wound healing.
In children with recent onset of toe extension contracture,
surgical manipulation of the volar plate of the MTP joint
capsule is usually unnecessary. A Kirschner’s wire of 0.020–
0.035 inch size is inserted through the proximal phalanx
to keep the digit in full extension while maintaining the
MTPJ in 45–60° plantar flexion. The wires are removed
10–14 days later, once the take of skin graft or flap is estab­
lished (Fig. 59.1).
While seldom indicated in children, joint capsuloplasty
that involves the volar plate of the MTP joint may be neces­
sary in adults or in a joint that has subluxed for a long period
of time. Mere release and skin graft/flap coverage of the
wound over the joint structures may not restore joint
alignment.
In order to minimize recurrent contracture of the toe joints
commonly associated with the use of skin grafting tech­
nique, a skin flap mobilized from the area adjacent may be
used, particularly in instances where the joint structure is
exposed. A 34 z-plasty technique is useful in achieving cover­
age of the joint structures and the wound defect (Fig. 59.2).
Contractural deformities of the anterior ankle
Tightness of the ankle joint with a dorsiflexion of the foot is
a common consequence of burn injury that is limited to
the anterior surface of the ankle. As in other deformities
noted in the foot, improper splinting of the foot and the
ankle joint, plus scar contracture, are the probable cause
©2012 Elsevier Ltd, Inc, BV
DOI: 10.1016/B978-1-4377-2786-9.00059-X
CHAPTER 59 
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Instead, the technique to fabricate a paratenon cutaneous
flap may be used.
The technique of 34 paratenon cutaneous (PC) z-plasty, a
variant of paratenon cutaneous z-plasty technique, is useful
for instances with extensive scarring with an uninjured skin
available for flap fabrication. A right-angled triangular skin
flap is marked with its cathetus perpendicular to the line of
scar release. The paratenon is included for flap fabrication.
The flap is rotated 90° to fill the defect resulting from release
(Fig. 59.3).
Scar deformities involving the sole of
the foot
Plantar flexion of the toes at all joint levels, i.e. the clawing
toe deformity, is the common deformity encountered in
instances where the dorsal surface of the toes is spared of
injuries. Plantar flexion of the toes compounded by contrac­
tion of the scar formed in the area is the probable cause of
this deformity.
of this undesirable consequence. Correction of an extremely
deformed ankle joint may require scar release and recon­
struction of deformed periarticular structures. Capsuloplasty
and re-routing of the tendons around the ankle joint are
oftentimes necessary.
Reconstruction of dorsiflexion contracture of the ankle
Although skin grafting is the most common technique used
to cover an open wound around the ankle, wound contrac­
ture is common. It is, furthermore, not effective for repairing
a wound with an exposed joint and tendons, a sequela com­
monly associated with joint realignment procedures requir­
ing elaborate joint structure reconstruction. There are two
approaches that are useful for scar release and wound cover­
age: the z-plasty technique and the 34 paratenon cutaneous
(PC) z-plasty.
The z-plasty technique of contracture release is used to release
a contractile scar across an ankle joint. However, a conven­
tional approach in elevating triangular skin flaps tends to
disrupt flap vascular supply thus causing flap necrosis.
Figure 59.1  (a) Burn contracture developed to cause hyperextension of the toes. (b) An incision made in the dorsum of the right foot at metatarsophalangeal
(MYP) joint level resulted in a large tissue defect. (c) The phalanges were flexed at MTP joint level and were maintained for 10–14 days. (d) Subsequently, a
high-top shoe was worn for the next 6–10 months to minimize recurrence.
A
B
C
D

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Figure 59.2  (a) A skin marking indicated the
incision line required to release a contracted right
fifth MTP joint. A triangular skin marking indicated
the skin flap. (b) A distally-based flap was
elevated with the underlying fascial layer
attached. (c) The flap was rotated medially to
cover the wound resulting from contractural
release. (d) The wound edges were closed.
A
B
C
D

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A
B
C
D
Figure 59.3  (a) Anterior surface of the left ankle showed the formation of moderately hypertrophic scar limiting ankle movement. (b) A skin marking
indicated a line of contractural release over the ankle joint; a triangular skin drawing marked a skin flap with underlying fascial and paratenon structures
attached. (c) The fascio-paratenon structures were identified. (d) A distally based paratenon cutaneous flap was fabricated. (e) The appearance of operative
site 1 year following the procedure.
E

Reconstruction of burn deformities of the lower extremity
675
Reconstruction of plantar flexion
deformities of the toe
Surgical release of the contracted scar at the site of contrac­
tion may not be necessary unless the magnitude of contrac­
tion interferes with the wearing of shoes.
The use of a composite skin flap mobilized from
the dorsum of the foot
Skin grafting technique is the best modality for reconstruc­
tion. Splinting of the foot and toes immediately following
surgery is an essential component of the post-surgical care
plan. Recurrence of the contracture is very likely without an
effective toe splinting maneuver.
Reconstruction of the deformities involving
the plantar surface of the foot
The problems are mostly related to breakdown of the graft
caused by pressure and shearing forces exerted by walking.
Although a local composite skin flap could be used to recon­
struct a small defect, breakdown of the skin with ulcer for­
mation is inevitable unless the flap is sensate. Restoration of
skin sensation to the pressure points is a pre-requisite for
successful patient rehabilitation.
Reconstruction of specific ankle deformities
Extensive burns of the foot and ankle area can lead to talipes-
like deformities of the foot, e.g. talipes equinus, varus and
valgus (Fig. 59.4). Reconstructive procedures will involve not
only the release of the capsular structure around the ankle
joint but also lengthening of the tendon of Achilles for an
equinus deformity, to restore the joint. In practice, the extent
of ankle restoration may be limited because of difficulty in
closing an open wound resulting from soft tissue release.
Use of skin flap in conjunction with skin graft is considered
for covering a wound with exposed tendinous and capsular
elements.
Reconstructing a talipes equinus-like deformity
A plantar flexion deformity that is most commonly caused
by an injury involving the heel of the lower leg. While con­
traction of the resultant scar could be the factor responsible
for the deformity, tendo-Achilles shortening could further
aggravate it. Surgical restoration of ankle mobility will
require lengthening of the Achilles tendon. The plan in
lengthening the heel-cord must include measures such as
fasciocutaneous z-plasty or
34 fasciocutaneous z-plasty
technique to close the heel wound that tendon structures
expose.
Reconstructing a talipes vera and
valgus-like deformity
Although delineation of the exact extent of tissue destruction
and scarring to cause an ankle deformity may be difficult,
releasing maneuvers can result in a wound with exposed
tendon and joint structures. Inclusion of a surgical plan for
wound coverage is essential to minimize morbidity. The use
of transpositional fasciocutaneous flap technique; alias 34
fasciocutaneous z-plasty, is useful. The technical details of
fasciocutaneous z-plasty and the 34 fasciocutaneous z-plasty
technique are described as follows:
The modified z-plasty technique that includes the
paratenon in flap fabrication; alias 3 4 paratenon
cutaneous z-plasty technique
Both techniques are essentially identical to the FC z-plasty
and 34 FC z-plasty. They are so termed because of inclusion
of the paratenon of the underlying tendon structures in flap
fabrication to assure vascular supply. In fabricating a flap,
the dissection of the tissue must include the paratenon over­
lying the tendinous structures. A composite triangular skin
flap, i.e. the skin and the paratenon located underneath, are
transposed (Figs 59.3, 59.5).
Reconstruction of flexion knee deformities
A knee joint contracture is mostly that of flexion. The inci­
dence, in comparison with other large joints, is relatively
uncommon. The deformities noted are usually caused by
improper use or lack of splinting. The deformities vary from
a tight scar band across the popliteal fossa to a frank knee
joint contraction. The treatment options vary according to
the deformities noted.
Non-surgical management
Although mechanical traction by pulling on an ankle is effec­
tive in correcting a contracted knee joint, splinting and/or
casting with progressive extension is a more common
approach used to correct a slight to mild joint contracture.
Long-term use of a knee splint, however, is needed to prevent
recurrence. In practice, patient compliance is low and tight­
ness across the popliteal fossa can persist. Surgical interven­
tion will therefore, be necessary.
Surgical management
The treatment options available to correct the deformity are:
(1) skin grafting; (2) z-plasty; (3) interpositional z-plasty
alias 34 z-plasty, and (4) interpositional random fasciocuta­
neous z-plasty alias 34 FC z-plasty.
Reconstruction of a contracted knee joint with
skin grafting technique
Scars that are contractive and thickened may be best
managed with excision and skin grafting. Complete removal
of fibrous tissues is necessary. On the other hand, the use
of a skin grafting technique may not be feasible if the pop­
liteal vessels and neural structures become devoid of overly­
ing soft tissues.
A partial thickness skin graft of 14–16/1000th of an inch
in thickness (STSG) is used most commonly for wound
coverage. Immobilization of the knee joint in full extension
for a period of 3 weeks followed by continuous use of pos­
terior knee splint for 9–12 months is necessary to minimize
recurrence of joint contracture (Fig. 59.6).
Reconstruction of a contracted knee joint with
an interpositional skin flap technique,
alias 34 z-plasty technique
Skin markings triangular in shape are made in the area with
unburned skin or pliable skin adjacent to the site of release.

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A
B
C
D
E
F
Figure 59.4  Showing examples of cicatricial ankle deformities caused by scarring and contraction of scars formed around the ankle joint. (a) Calcaneus
deformity. (b) Equinus deformity. (c) Valgus deformity. (d) Varus deformity. (e) Equinovalgus deformity. (f) Equinovarus deformity.

Reconstruction of burn deformities of the lower extremity
677
G
H
(g) Calcaneovarus
deformity. (h) Calcaneovalgus deformity.
Figure 59.4, cont’d
The cathetus of the triangle is made perpendicular to the
distal end of released wound. The flap length to width ratio
should be less than 2 : 1. The skin flap is rotated 90° to
complete the wound closure. The flap donor site is closed
primarily (Fig. 59.7).
Reconstruction of a contracted knee joint with
an interpositional fasciocutaneous (FC) flap,
alias 34 FC z-plasty
Inclusion of the underlying fascial layer is useful in fabricat­
ing a triangular flap with a flap length to width ratio in excess
of 2 : 1. Release of the joint surface may become necessary if
a scarred skin is used to fabricate the flap.
Other methods to reconstruct a contracted knee joint
A composite skin flap may be converted into an island flap
if the vascular supply to the area is readily known. The arc
of flap rotation is wider and the inset of the flap is technically
simpler and easier (Fig. 59.8).
The anterior lateral thigh perforator (ALT) flap
The flap1,2 may be thinned and trimmed as well as modified
to fit the wound contour. Harvesting a flap is technically
simple as the location of the vascular pedicle is consistent
and the vascular territory is large. Donor site morbidity is
nil. The ALT flap unfortunately has its anatomical limits; the
size of flap may not be sufficient to cover the whole defect;
variations occasionally are noted in the vascular patterns; the
flap may be bulky. Flap dissection may be technically cum­
bersome (Fig. 59.9).
Free muscle flap
A muscle flap harvested from a distant site and transferred
via microsurgical means is another treatment option avail­
able for deformity reconstruction.
Medial thigh perforator (MTP) flap or ALT-MTP
combination flap
Combining a ALT flap with MTP flap linked in sequence
and/or independently has been found to be useful in fabri­
cating a composite flap with its size sufficient to cover a large
wound.2,3 A MTP flap derives its vascular supplies from the
perforator of the superficial femoral artery.
After care and rehabilitation
The patient’s recovery from devastating injuries may depend
upon the effectiveness of reconstruction procedures.4 This
in turn is governed by the timing of surgical intervention

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A
B
C
D
Figure 59.5  (a) A moderate degree of left ankle contracture was noted. (b) The technique of transpositional fascio-paratenon-cutaneous flap, alias 34
fasciocutaneous z-plasty, was used for contracture involving the ankle joint. (c) The flaps were fabricated. (d) The flaps were moved into place to make up
the tissue defects resulting from releasing procedures. (e) The appearance of operative site 2 years following the operation.
E

Reconstruction of burn deformities of the lower extremity
679
Figure 59.6  (a) A persistent ulcer developed in the left popliteal fossa area for 3 years following burn injuries involving 65% of total body surface area.
(b) An open wound measuring 10 cm × 7 cm resulted from the scar and ulcer excision. (c) A partial thickness skin graft of 15–16/1000th of an inch in
thickness was used to cover the open wound. (d) Healing of the grafted area was uneventful. The appearance of grafted popliteal fossa 2 years later.
A
B
C
D