Reconstruction of the Burned Hand – an article review

Updated 3/2017-- all links removed (except to my own posts) removed as many no longer active. 

Going through a stack of journals that have piled up, I noticed a nice little article (full reference below) discussing reconstruction of the burned hand.  It’s a short, seven page article full of information.

Early treatment and aggressive management are critical to restoring optimal hand function following burn injury. It has been shown that an early, multidisciplinary approach to the care of the burned hand has led to a successful outcome in 97 percent of patients with superficial injuries and 81 percent of patients with deep dermal burns.

Early treatment is important for the best outcomes with burned hands.  If there is any question of degree or severity, refer hand burns to a burn center or specialist.

The article notes the various burned hand deformities can be classified into the following categories:

(1) hypertrophic burn scars and burn scar contractures

(2) claw deformity

(3) web space deformity

(4) the severely burned hand which may involve
many deformities simultaneously

The article discusses each of these malformations individually along with their management and reconstructive options.  This article is worth your time to read and reread.

REFERENCE

Reconstruction of the Burned Hand; Kreymerman, Peter A.; Andres, Lewis A.; Lucas, Heather D.; Silverman, Anna L.; Smith, Anthony A.; Plastic & Reconstructive Surgery. 127(2):752-759, February 2011; doi: 10.1097/PRS.0b013e3181fed7c1

Topical Silicone Gel for Burn Scars

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

I have read the studies the promote the use of silicone sheets for scar treatment.  I know the claims Mederma and other silicone gel scar treatments make.  What do I tell my patients? 

“It doesn’t matter what you use.  It matters that you use it.  Mederma is non-scented and less greasy than Vit E or cocoa butter.  If that will entice you into doing your dailyscar massage, then use it.”

For most scars, I will stand by the above.  Burn scar are characterized by an increasing occurrence of redness, thickness, stiffness, pain, and itching, and a disturbance in pigmentation and surface roughness.   So when I saw there was a new study looking at the use of silicone gel in the treatment of burn scars, I read it (full reference below).

Burn scars are often treated with intralesional corticosteroid injections, occlusive dressings, custom-made pressure garments, and silicone sheets. 

The silicone sheets, introduced in the early 1980s, have been shown to helpful in improving scar appearance.  The drawbacks of their use include compliance issues on scars in visible areas, difficulty of use for scars on or adjacent to joints, and hygienic issues of prolonged use.  The sheets can trap moisture creating skin irritation or rashes.

The article looks at a topical silicone gel named Dermatix (Meda Pharma, Amstelveen, The Netherlands).  It can be applied easily and dries to form a thin, flexible coating that does not restrict movement.  Unlike the silicone sheets, cosmetics can be applied over the silicone layer to camouflage the scar.

Martijn van der Wal, M.D., VU University Medical Center, Netherlands, and colleagues conducted a randomized, double-blinded, within-subject comparative, placebo-controlled trial to investigate the effectiveness of topical silicone gel in the treatment of scars resulting from a burn injury.

Forty-six scars on 23 patients were included in the study and followed for 1 year.  The mean age of the scars at inclusion was 4 months.   The patients were given two blinded and coded products to be applied two times per day on the two included scars with instructions to not interchange the therapies between the two scars.   One tube held a placebo cream and the other tube held Dermatix (kindly provided by Meda Pharma BV).  Effectiveness on scar quality was evaluated at 1, 3, 6, and 12 months using the Patient and Observer Scar Assessment Scale and the DermaSpectrometer.

Over all visits, the benefit on surface roughness was statistically significant (p = 0.012).   The surface of the topical silicone gel–treated scars showed significantly less roughness (p = 0.014) at 3 months after start of the treatment, and the topical silicone gel–treated scars were significantly less itchy (p = 0.018 and p = 0.013, respectively) at 3 and 6 months.

On average, observers rated scars treated with topical silicone gel slightly better than scars treated with the placebo cream, but repeated measures analysis did not show a significant treatment effect (p = 0.154). The patients rated the scars treated with topical silicone gel and the placebo cream almost equally.

So while topical silicone gel may improve the surface roughness of burn scars and aid in decreasing the itching, it is no better in improving the  overall appearance of the scar than the placebo.  To me this implies or suggests that the simple act of scar massage regardless of the cream/gel used may be the most important in aiding the appearance of the scar.

REFERENCES
Topical Silicone Gel versus Placebo in Promoting the Maturation of Burn Scars: A Randomized Controlled Trial; van der Wal, Martijn B. A.; van Zuijlen, Paul P.; van de Ven, Peter; Middelkoop, Esther; Plastic & Reconstructive Surgery. 126(2):524-531, August 2010; doi: 10.1097/PRS.0b013e3181e09559

Carbolic Gangrene of the Hand

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

I stumbled across an old surgery text, A Text-Book of Minor Surgery by Edward Milton Foote, MD, which was published in 1908 at an antique store a few weeks ago. I have enjoyed thumbing through it. There are photos of conditions I have only read of and never seen. Carbolic gangrene of the hand is one of those conditions.

Carbolic acid [car·bol·ic acid   (kär-bŏl'ĭk)]  is now more commonly known as phenol [phe·nol   (fē'nôl', -nōl', -nŏl')].    

1. A caustic, poisonous, white crystalline compound, C₆H₅OH, derived from benzene and used in resins, plastics, and pharmaceuticals and in dilute form as a disinfectant and antiseptic. Also called carbolic acid.

In 1865 Dr. Joseph Lister (1827-1912) began the practice of using an antiseptic in surgery.  He treated wounds with dressings soaked in carbolic acid.  Gangrene cases began to be reported around 1871.  Carbolic acid was commonly found in households during this time.  I’m not sure when that changed.

From Foote’s text (as are both photos):

If carbolic acid is spilled upon the skin accidentally, its caustic action may be prevented by promptly bathing the part with alcohol; but in most of the cases in which gangrene is produced a solution of the acid is employed, and the destruction of the skin, taking place slowly and often painlessly, is not recognized until hours have elapsed.  It is then too late for relief to be obtained by bathing with alcohol.

Gangrene has frequently been produced by the application of a five per cent solution of carbolic acid in water, and in some instances by the use of a watery solution of only one percent. 

Carbolic gangrene is dry and usually painless.  The affected part is at first dark gray or brown, and as the tissues dry and shrivel they grow darker, so that they become almost black.  In a few days a line of demarcation is established between the dead and living parts, and there is some swelling of the latter, due to absorption of septic material along the line of separation.  In a few cases this absorption my lead to a well marked cellulitis with the formation of pus pockets.

The treatment of carbolic gangrene is at first conservative.  The parts should be kept warm and dry, and amputation should be postponed until the line of demarcation through the skin is established.  Not until then is the surgeon able to decide positively how much of the finger can be preserved with benefit.  This delay of ten days or two weeks also increases the vitality in the partially damaged skin, so that it can be used successfully for a flap after two week, when the same flap would certainly not have been viable if amputation had been performed as soon as the gangrene was noticed.

Current day uses of phenol (or carbolic acid) includes deep chemical peels of the face.  Care must be taken with how long it is left on the skin to prevent a deeper burn than intended.  From the second reference article below comes this history of that use:

In September of 1961, Litton courageously presented 50 cases with a 2-year follow-up at the ASPRS meeting in New Orleans, Louisiana. Litton (personal communications, 1996 through 1999) told me he had paid a lay peeler by the name of Coopersmith in Fort Lauderdale, Florida, for the formula in 1958 or 1959. In his follow-up article published in this Journal in 1962, Litton  did not print a specific formula, saying only that a "minute" amount of croton oil was added to a 50% solution of phenol with glycerin and water. He wrote significantly that "croton resin" causes vesiculation and sloughing, but he did not reference those attributes and did not follow up on them. Biopsy photomicrographs at 3 months postoperative and four sets of preoperative and postoperative results were published.

In November of 1961, Baker contributed a specific easily measured and mixed formula in the Journal of the Florida Medical Association. One patient was identified in a photograph as having a 3-month follow-up. No specific number of patients was given. The Baker formula (1961) included the following:

* Phenol USP 88%: 5 cc, 47%

* Distilled water: 4 cc, 49%

* Croton oil: 3 guttas, 1.2% (correct percentage if 1 gutta = 27 drops per cc)

* Septisol: 8 guttas, 2.6%

REFERENCES

A Brief History of Wound Care; Plastic and Reconstr Surg 117(7S):6S-11S, June 2006; Broughton, George II; Janis, Jeffrey E.; Attinger, Christopher E.

An Examination of the Phenol-Croton Oil Peel: Part I. Dissecting the Formula; Plastic and Reconstructive Surgery. 105(1):227-239, January 2000; Hetter, Gregory P.

Is the Phenol-Croton Oil Peel Safe?; Plastic and Reconstructive Surgery. 110(2):715-717, August 2002; Bertolini, Thomas M.

Burn Care Resources

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

I received this request recently, so I thought I would try to put a list together.  Not sure it is the best list, but it’s an attempt.  If you have any additional resources, please add them in the comment section.  Thanks.

I was wondering if you would be so kind as to direct me to some biographical and historical resources on skin grafting in the treatment of burns.

Let’s first start with burn care / general information:

•  American Burn Association
• BurnSurgery.org -- a comprehensive, up-to-date Educational Tool  for burn care professionals throughout the world.
• Burn Survivor Resource Center (great information & links)
• John Hopkins Medicine
• Phoenix Society for Burn Survivors
• Total Burn Care by David Herndon, MD, FACS

The sites, journals, and books that deal with burn care will have information about skin grafting.  Here are some articles/ books that are just about skin grafting:

• On the History of the Free Skin Graft; Annals of Plastic Surgery, September 1982 - Volume 9 - Issue 3; Hauben, Daniel Joseph M.D.; Baruchin, A M.D.; Mahler, Dan M.D
• Skin Grafting by Ross, M. D. , Jack C. Fisher, M. D. , John L. Ninnemann, Ph. D. Rudolph (1979, book review from 1980)
• Skin Grafting in Burns; Wounds Vol 20, Jul 01 2008, Issue 7:  Chester N. Paul, MD, FACS
• The Mesh Skin Graft in Trauma: History and Preliminary Report on Acute Wound Coverage; The Journal of Trauma: April 1971 - Volume 11 - Issue 4 - ppg 347-351; SALISBURY, ROBERT B. LCDR, MC, USN

Support Groups for Burn Patients:

• Burn Survivors Online (in addition to forum has a nice list of books by survivors)
• Surviving Burns Support Services
• Burn Survivors Throughout the World, Inc.

Related posts:

Electric Burns to the Mouth (September 28, 2007)

Bioengineered Skin Substitutes (BSS) (August 17, 2007)

Dermatomes  (May 7, 2008)

Acute Burns -- When to Transfer (September 15, 2008)