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Burns of the Upper Extremity 0749-0712/90 $0.00 + .20 Acute Management of Pediatric HandBurns Howard M. Clarke, MD, PhD, FRCS(C),* Gregory P. Wittpenn, MD, Maj, USAF/f Aileen M.E. McLeod, MCSP, MCPA,$ Shawna E. Candlish; BMR, OT, OT(C),§ Cinthia J. Guernsey, BScN,[I Deborah K. Weleff, RN,** and Ronald M. Zuker, MD, FRCS(C), FACS’~f The choice between conservative treatment and aggressive early excision of hand bumshas been widely debated. With the introduction of topical antimicrobial agents, early tangential excision of the burn wound by Jan~.ekovi~, 8 and early aggressive therapy combined with the improved use of splints, the gnarled, function- less hand as a sequella of bum injury has become a rarity. Subsequent studies by Edstrom 6 and others, however, have shown no significant difference in function between hand burns treated with early excision and those healing spontaneously. The .burned hand in the child, in our experience, results from a different pattern of injury a and responds differently to therapeutic intervention compared with the adult hand. For these reasons, we have devel- oped a conservative approach to most injuries. A retrospective review of 226 consecutive burn admissions to The Hospital for Sick Chil- dren over a 3-year period (1986 to 1988) was performed. A total of 58 patients sustained burns below the elbow. One chart was unavail- able for review and 1 patient succumbedto the burn injury. The remaining 56 patients with 64 burned extremities were reviewed. The etiology of the bum wound in our pop- ulation was scald (37 per cent), flame (27 cent), contact (25 per cent) and others, includ- ing electrical (11 per cent). The more common flame burn injury in adults tends to produce a deeper injury compared with the typical child- hood scald. This favorable pattern in children allows us to treat the wound conservatively with twice daily rubbings, closed dressings, and ac- tive rehabilitation therapy. In this review we present a detailed descrip- tion of our approach to woundcare and briefly outline the nutritional and psychosocial aspects of pediatric burns. In addition, we discuss the From the Hospital for SickChildren, Toronto, Ontario,Canada *Assistant Professor, Division of Plastic Surgery, University o[’Toronto; Active Staff Surgeon, Division of PlasticSurgery tClinical Fellow, Division of PlasticSurgery ~Senior Physiotherapist, Department of Rehabilitation Services §Senior Occupational Therapist, Department of Rehabilitation Services ]lAssistantNursing UnitAdministrator, Bums and Plastic Surgery Unit **Resource Nurse, Bums and Plastic Surgery Unit ttAssociate Professor, Division of Plastic Surgery, University of Toronto; Director, Bum Unit Hand Clinics--Vol. 6, No. 2, May 1990

Acute Management of Pediatric Hand injury. The remaining 56 patients with 64 burned extremities were reviewed. The etiology

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Page 1: Acute Management of Pediatric Hand injury. The remaining 56 patients with 64 burned extremities were reviewed. The etiology

Burns of the Upper Extremity 0749-0712/90 $0.00 + .20

Acute Management ofPediatric Hand Burns

Howard M. Clarke, MD, PhD, FRCS(C),*Gregory P. Wittpenn, MD, Maj, USAF/f

Aileen M.E. McLeod, MCSP, MCPA,$Shawna E. Candlish; BMR, OT, OT(C),§

Cinthia J. Guernsey, BScN,[IDeborah K. Weleff, RN,**

and Ronald M. Zuker, MD, FRCS(C), FACS’~f

The choice between conservative treatmentand aggressive early excision of hand bums hasbeen widely debated. With the introduction oftopical antimicrobial agents, early tangentialexcision of the burn wound by Jan~.ekovi~,8 andearly aggressive therapy combined with theimproved use of splints, the gnarled, function-less hand as a sequella of bum injury hasbecome a rarity. Subsequent studies byEdstrom6 and others, 1° however, have shownno significant difference in function betweenhand burns treated with early excision and thosehealing spontaneously. The .burned hand in thechild, in our experience, results from a differentpattern of injury a and responds differently totherapeutic intervention compared with theadult hand. For these reasons, we have devel-oped a conservative approach to most injuries.

A retrospective review of 226 consecutiveburn admissions to The Hospital for Sick Chil-

dren over a 3-year period (1986 to 1988) wasperformed. A total of 58 patients sustainedburns below the elbow. One chart was unavail-able for review and 1 patient succumbed to theburn injury. The remaining 56 patients with 64burned extremities were reviewed.

The etiology of the bum wound in our pop-ulation was scald (37 per cent), flame (27 cent), contact (25 per cent) and others, includ-ing electrical (11 per cent). The more commonflame burn injury in adults tends to produce adeeper injury compared with the typical child-hood scald. This favorable pattern in childrenallows us to treat the wound conservatively withtwice daily rubbings, closed dressings, and ac-tive rehabilitation therapy.

In this review we present a detailed descrip-tion of our approach to wound care and brieflyoutline the nutritional and psychosocial aspectsof pediatric burns. In addition, we discuss the

From the Hospital for Sick Children, Toronto, Ontario, Canada

*Assistant Professor, Division of Plastic Surgery, University o[’Toronto; Active Staff Surgeon, Division of Plastic SurgerytClinical Fellow, Division of Plastic Surgery~Senior Physiotherapist, Department of Rehabilitation Services§Senior Occupational Therapist, Department of Rehabilitation Services]lAssistant Nursing Unit Administrator, Bums and Plastic Surgery Unit**Resource Nurse, Bums and Plastic Surgery UnitttAssociate Professor, Division of Plastic Surgery, University of Toronto; Director, Bum Unit

Hand Clinics--Vol. 6, No. 2, May 1990

Page 2: Acute Management of Pediatric Hand injury. The remaining 56 patients with 64 burned extremities were reviewed. The etiology

Howard M. Clarke e,t al.

surgical approach used in our unit and therehabilitation of hand burns. Lastly, the resultof this integrated approach is presented.


Bum injuries by their very nature interferewith the protective function of the skin, ren-dering the burn wound susceptible to dessica-tion and infection. The primary goal of woundcare must be to prevent infection and its seque-lae Of conversion of the wound, damage todeeper structures, or worst of all, systemic

dissemination.7 In addition, meticulous woundcare facilitates the preservation of function andallows for appropriate therapy and positioning,which is particularly important in the hand. Thedescription of wound care that follows, althoughpertaining to all anatomic regions, concentrateson the child’s hand.

Positioning of the involved hand is especiallyimportant in the younger child, since the activemuscle pump only minimally assists in thereduction of edema. While in bed, the hand iselevated above the level of the heart by pinningthe dlressing to pillows or wedges. If the childis ambulatory, elevate the hand in a sling.

With a partial thickness burn injury, escharcan be removed gradually by mechanical de-bridement with each treatment, facilitatingspontaneous epithelialization. This delicate ep-ithelium is protected with ointment-impreg-nated dressings and an antibacterial ointment.The 1:oll or splint and web spacers are contin-ued. As wound healing progresses, the healeddigits are exposed to aid in desensitization andto encourage the child to start using the hands.

Closed-Wound Phase

Open-Wound Phase

The open-wound phase refers to the period.from burn insult to final closure of the wound.The child is bathed in a hydrotherapy tub, withnormal saline solution, twice a day. Woundsare washed carefully to remove all loose exudate¯ and debris. Nonviable tissue is removed fromthe wounds using forceps and scissors with eachtreatment (mechanical debridement). Unbro-ken. blisters are left intact, if feasible, to providea moist, sterile environment for wound healing.

Specific burn dressings for the hand are de-signed through collaboration between the nurseand the therapist. Individualized range-of-mo-tion exercise programs are formulated by thetherapist and are implemented at dressingchanges by either the therapist or the nurse.

Dressings are changed under sterile tech-nique with liberal application or topical silversulfadiazine to the burn (Fig. 1). The functionalhand position is maintained by placing largeweb spacers (5 x 2 cm pieces of gauze) betweeneach digit (Fig. 2) and a soft roll of gauze in thepalm (Fig. 3), thereby achieving maximum dig-ital abduction and thumb opposition. The trans-verse arch is also maintained with this position-ing routine. The roll in the palm is unnecessaryif a splint is used for positioning, but webspacers remain essential (Fig. 4).

The closed-wound phase begins with eitherspontaneous epithelialization or skin grafting.Skin :grafting is often necessary for wound clo-sure ~th a full thickness or deep partial thick-ness burn injury. After the grafting procedure,dressiings are secured with a partial cast orsplint, which immobilizes the hand and wristto avoid shearing of the grafts. Hands are ele-vated either on pillows or with a suspensiondressing. Dressings are removed by soaking inthe hydrotherapy tub 7 to 10 days after grafting.Graft.,; that have taken well will appear pinkishand will have adhered smoothly to the base.Crusting may occur on or around the grafts andwill llft off with further soaking and lubrication.Small vesicles that may appear can be piercedwith a sterile needle and expressed. Initially,ointment-impregnated dressing and an antibac-terial ointment are used in conjunction with alight gauze dressing. Once the grafts are secureand can be left exposed without the threat ofinjury (usually 3 to 5 days) or the wound hashealed spontaneously, a moisturizing cream isapplied several times a day to combat dryness.


Nutrition is an important factor in promotingwound healing and preventing infection. The

Page 3: Acute Management of Pediatric Hand injury. The remaining 56 patients with 64 burned extremities were reviewed. The etiology














Figure I. Topical silver sulfadi-azine is liberally applied to thecleansed, debrided hand.

Figure 3. A soft roll of gauze isplaced in the palm and the hand ismolded into the position of func-tion around it.

Acute Management of Pediatric Hand Burns ~3

Figure $. Large xveb spacers arecarefully placed between .all thedigits to enhance abduction.

Page 4: Acute Management of Pediatric Hand injury. The remaining 56 patients with 64 burned extremities were reviewed. The etiology

Howard M. Clarke et al.

child with bums has increased caloric and pro-tein requirements. In addition, nutritional sup-port must meet the child’s normal growth anddevelopmental needs. It is rare, particularly inthe younger age groups, for a burned child toconsume enough calories and protein to meetthese combined requirements. The hospitalizedchild may refuse to eat because of separationfrom family and surroundings, general malaise,the restrictions of dressings, or differences incultural background. The child may refuse toeat as his only means to exercise control overthe situation.

The need for supplemental nasogastric feedsis not determined by the size of the burnedarea. If the child is unable to consume 50 percent of his baseline plus bum caloric and proteinrequirements by mouth, nasogastric tube feed-ing is initiated. Feeds are started early, reach-ing the child’s optimum nutritional require-ments within the first 48 hours after the bumoccurred.

The nutritional status of the child should beassessed and followed closely using dailyweights and calorie counts. The nurse shouldwork closely with the dietician to accomplishthese goals.


Any bum injury to a child places addedemotional stress on the family unit. Certainly,bum injuries to a child’s hand raise many pa-rental concerns such as fear of loss of functionand altered appearance. Parents often feelguilty regarding the cause of their child’s inju-ries. It is therefore very important for a social

Figure 4. The completed, occlu-sive dressing effectively immobi-lizes the hand in the desired posi-’don.

worker to be actively involved from admissionto discharge and beyond, and to keep parentswell informed of their child’s care and progress.This contact helps to decrease any unwarrantedfears: and anxiety.


The most important objective of pain man-agement is that the child be comfortable andtolerate painful procedures with a sense ofcont~rol. The child must also be able to enjoythe remainder of the day pain free to play, eat,and rest comfortably. Good communication isrequired to document the specifics that helpeach child with pain control. Consistency ofcare helps the child to feel more secure andless anxious.9

Narcotic analgesics are given before tub pro-cedures, although some older children mayprefer medication immediately after dressingchanges. Other methods of pain control includethe use of distraction such as play, music, toys,television, ~ and the use of imagery and relaxa-tion techniques. School-age children and ado-lescents like to participate in their own care asmuct~ as possible in ways such as helping toremove cream. However, time limits and con-tract:; must be made between the child andcaregiver.



Deciding whether or not to graft bums to thehand of a child can be extremely difficult. This

Page 5: Acute Management of Pediatric Hand injury. The remaining 56 patients with 64 burned extremities were reviewed. The etiology

Acute Management of Pe,rliatric Hand Burns

decision is related, in part, to the epidemiologyof childhood burns.3 Many are scald injuries,which are of indeterminate depth. The otherimportant difference in childhood burns is thatthe hand will withstand immobilization throughlonger periods of time without significant resid-ual stiffness, allowing the clinician the oppor-tunity to defer the decision about grafting.

Immediate surgery in burns of the hands inchildren is limited to escharotomy..Escharoto-mies should be considered in any patient withcircumferential burns to the fingers, hand, orforearm. Assessment of the vascular supply tothe tips of fingers can be made both clinically,by using capillary refill and turgor, and also byusing various forms of instrumentation, such asDoppler flowrneters, to assess digital arteryflow. Escharotomy should be undertaken in anyhand in which there is a serious concern aboutthe circulation to the digits.

Scald burns of the hand can often be left toallow full demarcation of full thickness, andpartial thickness areas. In small children it ispossible to maintain a satisfactory range of mo-tion while still applying occlusive burn dress-ings. Fastidious nursing care is the key toprovide safety in deferring treatment in handburns. Two to 3 weeks of spontaneous healingare allowed before making a final decision aboutgrafting.

Flame burns commonly require skin grafting.In these cases, the areas of full thickness lossmay be apparent at initial assessment. Eschar-otomies will have been performed and earlysurgery can be undertaken with excision of theburn sear in a tangential fashion and grafting.

Contact burns can lead to significant skinloss. This often occurs on the palmar surface ofthe hand, which is otherwise usually spared fullthickness injury owing to its thickness. Evenvery narrow areas of burn on the palmar surfacemay require grafting, particularly ff they arealigned along the flexion arc of the finger. Thismay reduce the likelihood of contracture of thesmall joints of the hand, although secondarysurgery is often required.

Timing of Surgery

Although many authors have demonstratedthat early surgery should be undertaken in hand


burns to provide early mobilization, our expe-rience has shown that it is possible to defer~urgical management of burned hands in chil-dren and still achieve full mobilization. Theadvantage of this approach is that it allows moreaccurate assessment of the burn wound. Inaddition, burns over the extensor surface of the:fingers, which can be extremely difficult to,rlebride given the very thin skin and subcuta-neous tissue overlying the extensor peritenon,can be allowed to separate sothat only minimaldebridement is required.

Surgical Technique

Escharotomies can be performed in an awakepatient without anesthesia. Escharotomy inci-sions should be carried down the midlateral and.midmedial aspects of the forearm and extendfrom those incisions along the radial aspect ofthe thumb and ulnar aspect of the little finger.Any involved digits should have midlateral in-cisions made on both sides throughout theentire extent of the eschar and extending to thepulp of the finger. In electrical injuries, fasci-otomies are usually required, and it is advan-tageous to shift the incision to the palmar sur-face and undertake a wide S-shaped incisionsuch that the carpal tunnel can be releasedthrough the base of this wound.

Escharotomy incisions should transgress theentire thickness of the dermis exposing theunderlying fat. Restoration of distal perfusioncan then be monitored. Hemostasis is some-times required but usually light pressure willstop bleeding from the escharotomy wound.Significant amounts of fluids will ooze fromescharotomy sites and an appropriate burndressing must be applied.

Debridement of hand burns remains a matterof individual preference for different surgeons.Debridement of the upper extremity can beundertaken under tourniquet control to reducethe risk of producing significant blood loss in asmall child. A .number of specific techniqueshave been described.

The full thickaess eschar can be excised intoto in a" single swath using a dermitome. Al-though this technique is commonly used onother parts of the body in flame burns, it isuncommon to use it in hand burns, where the

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226 Howard M. Clarke et al.

risk to vital structures is great and the bestpossible scarring is desirable.

The technique of tangential excision involvesremoving, in a serial fashion, very thin layersof the eschar from the burn surface. This de-bridement .is repeated until healthy bleedingtissue is encountered. In this way it is hopedthat the maximum amount of viable dermis ismaintained to provide a better base than fat forskin grafting and to allow for improved scars.Although this technique is frequently done.without a tourniquet so that the bleeding pat-~

tern can be appreciated, it must be understoodthat significant bleeding can occur from such aprocedure. Immediately upon debridement,the wounds can be covered in fine mesh gauzesoaked in a solution of normal saline, thrombin,and neosynephrine. This not only keeps thewounds moist but reduces substantially theamount of bleeding from the wounds. Pressurecan be applied by wrapping the extremity in agauze or flannel bandage.

If the wound has been allowed to separatespontaneously, only a limited debridement ofthe granulation tissue may be required. If thetissue is sufficiently healthy, a simple wipe witha damp or dry gauze may provide adequateremoval of any debris on the surface. If granu-lation tissue has become mature, it may benecessary to debride more rigorously with theblunt edge of Howarth elevator or the back ofa scalpal blade or handle. If the granulationsare hypertrophic and appear not to be an ade-quate bed for skin grafting, frank excision of thegranulation tissue may be required with a der-mitome.

Given the size and area of hand burns com-monly seen in practice, the usual donor site inchildren is the buttock. The patient can bepositioned in the decubitus position and boththe extremity and buttock can be prepared anddraped with ease. The hip and knee are flexedto place the buttock skin under tension for skingraft harvesting. Dressings of the surgeon’schoice can be applied to the donor site withcare to provide a seal between the perineumand dressing using waterproof tape.

In most cases sheet grafts are used in handburns because the esthetic result is substantiallybetter. Entire units of the hand, such as thedorsum of a digit orof the hand itself, can begrafted with separate sheets. Although skin

grafting of the palmar surface of the hand is notcommonly required, sheet grafts are used. Thegrafts can be secured using staples in olderchildren or with chromic sutures in infants andsmall children. The hand can then be immobi-lized, either internally, using K-wires placedthrough the metacarpal heads and along theaxis of each finger, or externally, using a plasterbandage. In children the wrist is immobilizedin flexion after grafting the dorsum of the hand,even though this is not the position of function.One week to 10 days of immobilization in thisposition does not leave significant residual stiff-ness in the wrist and allows for full coverage ofthe burn area.

It is far easier to apply a secure dressing tothe grafted extremity of a young child undergeneral anesthesia in the operating room thanto struggle on the ward attempting to salvage apoorly applied dressing. Dressing materials insmall sizes are required and in children underthe age of 6 the partial plaster or splint isapplied to an above-elbow level to secure thedressing from sliding down the forearm. Variousadhesives can be used to fix the bandage to thenormal skin of the extremity. A suspension,dressing is required to minimize edema.


Infection in burn wounds may lead to delayedhealing, loss of skin grafts, and systemic sepsis.Prevention is most efficacious, using the woundmanagement .principles outlined above, Routineprophylactic systemic antibiotics are not used,although some surgeons use systemic penicillinin the initial treatment of scald burns if strep-tococcus is prevalent in the family or commu-nity. This issue remains controversial.

Infected wounds require urgent excision andextremely dose monitoring of systemic signs.Colonization of the wound, however, does notpreclude grafting.

Postoperative Care

Skin-grafted hands should be immobilized forat least 1 week in small children. The dressingsecured in the operating room is the mosts-’ttisfactory dressing that can be applied and to

Page 7: Acute Management of Pediatric Hand injury. The remaining 56 patients with 64 burned extremities were reviewed. The etiology

Acute Management of Pediatric Hand Burns

change this at several days requires more co-operation than the average small child can pro-vide. By waiting 1 week after grafting, all healedareas will be manifest and any areas that havesloughed will come off with the dressing.


Deep thermal injuries to the hand present aspecific and significant challenge to the rehabil-itation team. The challenge is to manage theshort lever arm available in the application oftreatment modalities. In the young child this isfurther complicated by their lack of musclestrength to oppose the force of the contractingbum scar and by their inability to understandand cooperate in the treatment process. Toovercome the identified problems and achievean optimal outcome, a comprehensive protocolof early motion, protective positioning, andsplinting is recommended.

Intrinsic factors that affect prognosis followingthermal injury to the hand are the anatomiclocation, depth of burn, rate of healing, hered-itary potential of the individual to develop scartissue, physiologic contractile forces active inwound healing, sear maturation, and age.z 4. 5The young child tends to form more scar tissue.Extrinsic factors that affect prognosis are thetherapeutic intervention, follow-up, and paren-tal and patient compliance.

The goals of pediatric bum therapy are tomaintain normal function, improve compro-mised function, and prevent the developmentof deformities. Intervention by physical andoccupational therapy can encompass protectivepositioning, splinting, exercise, massage, de-sensitization, age-appropriate activities, andnormal motor development.

Open-Wound Phase

Rehabilitative management begins in theearly acute phase and continues throughout thehospitalized period. Bum area and depth areassessed and analyzed for potential problems ofswelling, tendon rupture, and contracture. Inthe open-wound phase, the position of comfortin flexion may increase the contracture of thebum wound surface.


For superficial partial thickness bums, thehand is managed by a free active exercise pro-gram and positioning routine. The functionalhand position is incorporated into the bumdressing as previously described.

The young child does not understand theneed to protect vital structures that may be atrisk for further damage in the open-woundphase in deep hand bums. Specific positioningand a gentle, passive exercise program is de-veloped to minimize this risk. In deep bumst~hat involve the dorsum of the digit, the exten-sor mechanism may be compromised. In theyoung child active exercises are limited to meta-carpal-phalangeal joint flexion and extensionwith the interphalangeal joints maintained infall extension, abduction and adduction of thedigits, and thumb opposition to the finger tips.qfhe rationale for joint protection is not easilyunderstood by this age group and active fistingis discouraged. A protective, passive exerciseroutine is designed so that each joint will beput through gentle, full passive range of motionindependent of the other joints. The remainingjoints of the digit being mobilized are held in afully extended position to protect the extensormechanism. In the older child, each joint ismoved through full, active range of motionindependently while the adjacent joints are:~tabilized in the extended posture.

The volar bum does not typically compromisethe flexor tendons. There limitations in’the active exercise routine. The younger childis encouraged to use the hand in water play,’which is a relaxing and comfortable medium inwhich to achieve the full benefit of unrestrictedmovement. As well as performing free activeexercises, a specific passive exercise routine isaimed at maintaining the palmar spread bymaximizing the mobility of the first, fourth, andfifth metacarpals into extension and abduction.At the same time, the fingers and thumb arestretched gently into hyperextension.

Appropriate passive exercises are repeatedtwice ff full range is achieved easily. If skin orjoint tightness becomes apparent, however, therepetitions are increased until full range ofmotion is regained. The exercise program isperformed twice daily after the wounds havebeen cleaned and just prior to dressing.

Splints are used in hand bums that aregauged to be of sufficient depth to produce

Page 8: Acute Management of Pediatric Hand injury. The remaining 56 patients with 64 burned extremities were reviewed. The etiology

significant scars or to require grafting. In volvarbums, however, this decision may be deferreduntil the wounds have declared themselves,eliminating direct contact with the splint as afurther cause for burn wound conversion inmore superficial injuries.

When splinting the hand of the infant andtoddler, one must consider that the digits areshort lever arms and are therefore difficult toimmobilize in the adult resting position ofmeta-earpal-phalangeal joint flexion and interphalan-teal joint extension. The child can easily escape:the splint in this position by actively flexing themetaearpal-phalangeal joints, resulting in thehand becoming fisted within the splint. To solvethis problem, the effective lever arm is ex-tended to include the metacarpals, and the handis positioned in full metacarpal-ph_al_angeal andinterphalangeal joint extension and finger ab-duction. The positions for the thumb and wristare dependent on the specific burn. The splintis held in place with a conforming lid of similarmaterial producing a bivalved orthosis. For theolder child the position of the hand is similarto the approach described for the adult, withthe metacarpal-phalangeal joints positioned insixty degrees of flexion and the interphalangealjoints in ten degrees of flexion. Gauze bandageis wrapped lightly to hold the splint in position.

The material of choice for splint fabricationis a low temperature thermoplastic. The splintis worn continuously except for hydrotherapysessions and is cleaned with a warm solution ofsoap and water.

Closed-Wound Phase

Rehabilitative management in the closed-wound phase must address the intrinsic factorsin burn wound healing. The natural course ofthe burn scar is to contract, resulting in classichand deformities. The increase in blood supplyand cellular activity, which causes hypertrophicscar formation, is affected by compression ofthe scar. The key principles in therapy for burnscar contractures are elongation and compres-sion.

In deep dorsal burns the contractile forcesresult in a deformity of metaearpal-phalangealhyperextension, adduction and extension of thethumb, and flattening of the transverse palmar

arch. If the wrist is involved it may be pulledinto extension. The interphalangeal joints willbe pulled into flexion as a result of the tenodesiseffect and the greater strength of the long flexortendons.

Active range of motion is encouraged throughage-appropriate play with resisted activities. Inthe young child, the lack of muscle strength toovercome the contractile forces of the burn scaris a handicap; therefore, an aggressive exerciseprogram is of primary importance. For the childwho is unable to make a full fist actively, aprogram of sustained passive stretching withmassage is used 4 times daily until full range isregained. The child is then encouraged to main-tain this range through active play, and empha-sis is placed on resisted grip activities. Strength-ening of the long flexors and the intrinsicmuscles of the hand is important in limiting thepotential for deformity.

In the closed-wound phase, the bivalvedsplint used in the young child is modified togain twenty degrees of metacarpal-phalangealjoint flexion. Dynamic flexion splinting may berequired as an adjunct to the passive exerciseroutine. The most common approach is to usea flexion mitten that is attached to a wrist cuff(Fig. 5). Hooks glued to the fingernail arecontraindicated, since traction forces applied tothe nail in a child under 5 years can result indamage to the immature nail bed or avulsion ofthe nail plate.

Volar burns of the hand in the younger agegroup are typically contact burns. The thumblies in a plane perpendicular to the palm so theradial aspect of the thumb is often involved.Scar. contracture can result in a typical defor-mity of finger flexion, radial deviation of thethumb, and decreased palmar spread with ad-duction and opposition of the first, fourth, andfifth metacarpals. If the burned area extendsonto the volar surface of the forearm, the re-sultant deformity will be wrist flexion.

In the closed-wound phase of deep volarburns, the most significant passive stretches arefinger extension with abduction and palmarspread to flatten the transverse arch with thumband little finger abduction and extension (Fig.6). Activities to promote total active extensionare encouraged, for example, pushing a largeball against resistance and crawling.

After the wound is closed, the splint is

Page 9: Acute Management of Pediatric Hand injury. The remaining 56 patients with 64 burned extremities were reviewed. The etiology




Acute Management of Pediatric Hand Burns

Figure 5. A flexion mitten maybe used as a dynamic splint toachieve flexion in dorsal hand

adapted to position the metacarpal-phalangealjoints in ten degrees of hyperextension and thewrist in thirty degrees of extension. Delta-shaped dense foam wedges are added to theplatform to maintain finger abduction (Fig. 7),and the thumb is positioned to gain appropriateelongation of the burn scar. For the older child,a conforming rigid lid is fabricated. Velcro(Smalley & Bates, Cedar Grove, New Jersey)straps are added at this stage to facilitate appli-cation.

A custom-made insert of 30 per cent RolyanSilicone Elastomer (Smith & Nephew Rolyan,Menomonee Falls, Wisconsin) and 70 per centProsthetic Foam (WFR/Aquaplast Corp., Wyck-off, New Jersey) reinforced with a central layer

of gauze is applied directly to the area beingcompressed and is held in place by the splint,u

’This splint and insert routine provides com-pression and maintenance of lubrication of thescar in the elongated position. The combinationof rigid orthoses and silastic insert (Fig. 8) worn at all times for the first month followingwound closure and removed only for skin care,cleaning of the splint and insert, and a specificexercise routine. The insert is boiled in a mix-ture of one part vinegar and two parts wateronce a week. The splint and insert routine isdiscontinued during waking hours after the firstmonth and the child is fitted with a custom-made compression glove. Age-appropriate ac-tivities are encouraged when the child is wear-

Figure 6. Stretching routines forpalmar bums emphasize palmarspread and capitalize on the mo-bility of the first, fourth, and fifthmetacarpals.

Page 10: Acute Management of Pediatric Hand injury. The remaining 56 patients with 64 burned extremities were reviewed. The etiology


Figure 7. The posture of the burned hand in the splintshows maintenance of thumb and digital extension andabduction.

ing the glove. Otoform K (Dreve, Unna, WestGermany) web spacers are often used insidethe gloves to minimize webbing.

portant adjunct to provide lubrication, aid instretching the scar, ’and desensitize by provid-ing tactile stimulation. Deep finger-tip mas-sage along the line of potential contracturew:ith a tailored stretching and exercise pro-gram is performed four times daily. Otherdesensitization techniques include rubbingthe healed burn area with different texturesand finding objects hidden in different im-mersion substances (such as foam chips, rice,

¯ and macaroni). This combination of glove,splint, and insert routine is continued withthe massage and exercise program until scarmaturation is complete.

Dynamic extension splinting can be used incolajunction with the compression glove for thepreschool-age and older child. However, it isdifficult to obtain the optimum leverage in theilJ~t and toddler ~oup, and patient compli-an|2e is poor.

A knowledge of normal development is criti-cal when treating children. Because of the re-straining nature of bandages, splints and scareontraeture, it is necessary to facilitate normaldevelopmental movement patterns in the activetreatment program. For example, a 7-month-old child should be encouraged to weight-bearin the four-point crawl position to facilitateproximal control of the shoulder girdle muscu-lature and to encourage development of thepalmar arches in the hand.

Figure 8. Bivalved rigid splintwith delta wedges to achieve ab-duction of digits (center and right)shown with conforming insert(/eft).

Page 11: Acute Management of Pediatric Hand injury. The remaining 56 patients with 64 burned extremities were reviewed. The etiology

Acute Management of Pediatric Hand Burns231

Figure 9. This 19-month-oldchild sustained scald burns to thehand from hot oil in a kitchenaccident. Burns were diagnosed asdeep partial thickness, and after .waiting 19 days for partial healing, " "remaining open areas were grafted.


In 64 burned extremities treated in 56 pa-

tients, the majority of the wounds healed spon-taneously (72 per cent). Most patients werehealed within 3 weeks (89 per cent), includingthose patients being grafted by the third week.The percentage of patients in each group re-quiring grafting was 38 per cent for flame burns,28 per cent in contact burns, and 14 per centin scalds. These statistics support our impres-sion that less severe injury occurs in the scaldburn.

Children are more resilient in their responseto prolonged immobilization. Bivalve splints,with inserts for younger patients and staticsplints for older children, were used in 18 per

cent of patients once the burn wound wasdosed. The patients receiving these deviceswere those requiring grafts or those with deeperspontaneously healing wounds who were be-lieved to be at risk for contracture. Childrenform hypertrophic scars more readily. To coun-teract this, some form of compression garmentwas used in 46 per cent of our patients, specif-ically those with deeper burns or those dem-onstrating this tendency in the early follow-upperiod.

Of the 56 patients reviewed, 12 were lost tolong-term follow-up (21 per cent). Of the re-maining patients, 91 per cent were judged tohave normal function (Figs. 9 and 10). Of the

that did not, 1 lost all of the digits on theinvolved hand because of the severity of the

Figure 10. The same patient asin Figure 9 following treatmentwith a bivalve splint with insertsand then a compression glove for16 months. Excellent flexion at fol-low-up 2 years after the burn isdemonstrated.

Page 12: Acute Management of Pediatric Hand injury. The remaining 56 patients with 64 burned extremities were reviewed. The etiology

232 Howard M. Clarke et al.

burn, 1 had normal motion but decreased grip

strength, and 2 required secondary reconstruc-tive procedures.


The pattern of injury seen in pediatric hand

burns differs from adults because scald burnsare most common. Many of these are difficultto assess at initial presentation. In addition,

children develop less stiffness in response to

immobilization. For these reasons, we havedeveloped a conservative, expectant approachfor treating most pediatric hand burns.

Meticulous wound care, positioning, splint-ing, and exercise are required to safely accom-plish the goals of rapid healing with minimalloss of function. These regimens are adapted

specifically to suit the age of the child and areapplied by the burn team. Normal hand func-

tion can be obtained in the majority of cases.


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11. Zuker RM, McLeod AME, Vaz H, et al: Effectivemanagement of deep scald burns to the feet. J BurnCare Rehabil 5:288, 1984

Address reprint requests to

Howard M. Clarke, MD, PhD, FRCS(C)The Hospital for Sick Children

555 University AvenueToronto, Ontario MSG IX8