Comprehensive Management Comprehensive Management of Hand Burns of Hand Burns C. Scott Hultman, MD, MBA, FACS Chief and Program Director, Division of Plastic Surgery Associate Director, NC Jaycee Burn Center University of North Carolina, Chapel Hill May 2010
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NC DHSR OEMS: Comprehensive Management of Hand Burns
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Comprehensive Management of Hand Burns
Comprehensive Management Comprehensive Management of Hand Burnsof Hand Burns
C. Scott Hultman, MD, MBA, FACSChief and Program Director, Division of Plastic Surgery
Associate Director, NC Jaycee Burn CenterUniversity of North Carolina, Chapel Hill
May 2010
University of North Carolina Jaycee Burn Center
University of North Carolina University of North Carolina Jaycee Burn CenterJaycee Burn Center
• Regional Burn Center (6 states)– North Carolina: 9.5 million people
As a plastic surgeon who is committed to the care of burn patients, I would like to provide the full spectrum of care to people with this injury, which includes not only resuscitation and resurfacing, but also rehab, recon, and restoration of image. Too often, however, patients do not have access to cosmetic services, through lack of education, little financial resources, denial by insurance companies, or no available providers. With the recent closure of several burn centers in the Southeast, this problem will only get worse over time.
VMVM--plastyplastyjumping man Zjumping man Z--plastyplasty
dorsaldorsal
volarvolar
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. . .a variety of local tissue flaps. Many of these techniques, however, do not permit complete release of the web space and depend upon scarred, burned tissue for reconstruction.
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STARplastySTARplastyTechniqueTechnique
HultmanHultman CS, CS, Ann Ann PlastPlast SurgSurg, 2005, 2005
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It occurred to me that many of these techniques did not take full advantage of the relatively uninjured, supple skin of the volar surface of the web. Secondly, none combined longitudinal and oblique releases. The STARplasty was developed to utilize tissue from the digital sidewalls and permit the maximum lengthening and widening of the web space.
• Reintegration– Neuro-psychiatric Support– Functional Capacity Evaluation– Vocational Rehabilitation– Return to Work
Hot Press Hand Injuries:A Paradigm for Multidisciplinary Management
C. Scott Hultman, MD, MBA, FACS
SESPRSPuerto RicoJune 2009
UNCUNC
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PlasticPlastic
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SurgerySurgeryLeading through Innovation, Serving with CompassionLeading through Innovation, Serving with Compassion
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•• crush and thermal crush and thermal component component
•• wide range of wide range of morbidity morbidity
•• limited number of limited number of published reportspublished reports
•• longlong--term outcome term outcome unknownunknown
IntroductionIntroductionHotHot--Press Hand InjuriesPress Hand Injuries
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Hot-press hand injuries include both a crush and thermal component and can cause a wide range of morbidity. There exists a limited number of published reports, and the long-term outcomes are unknown
HotHot--Press Hand Burn Treatment, Press Hand Burn Treatment, AchauerAchauer et al,et al, J Burn Care J Burn Care RehabilRehabil 1998, 19;1281998, 19;128--130130
•• ““normal hand function,normal hand function,”” ““goodgood”” cosmesiscosmesis
•• one complication (minor graft loss)one complication (minor graft loss)
•• no secondary reconstruction performedno secondary reconstruction performed
IntroductionIntroductionHotHot--Press Hand InjuriesPress Hand Injuries
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Previous work . . .
•• to provide a comprehensive, longitudinal, to provide a comprehensive, longitudinal, institutional review of hotinstitutional review of hot--press hand injuriespress hand injuries
•• to assess functional morbidity, need for to assess functional morbidity, need for secondary reconstruction, and vocational secondary reconstruction, and vocational rehabilitationrehabilitation
•• to propose recommendations for managementto propose recommendations for management
PurposePurposeHotHot--Press Hand InjuriesPress Hand Injuries
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The purpose of this study is to provide a comprehensive, longitudinal, institutional review of hot-press hand injuries, assessing functional morbidity, need for secondary reconstruction, and vocational rehabilitation, and to propose recommendations for management.
•• December 1994 to December 2008 December 1994 to December 2008
•• North Carolina Jaycee Burn CenterNorth Carolina Jaycee Burn Center
•• MultiMulti--disciplinary team of surgeons, hand disciplinary team of surgeons, hand therapists, rehabilitation counselors, social therapists, rehabilitation counselors, social workers, psychologists, and chaplainsworkers, psychologists, and chaplains
MethodsMethodsHotHot--Press Hand InjuriesPress Hand Injuries
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Using a prospective database, we identified 56 patients with hot-press hand injuries who were treated from 1994-2008, at an accredited regional burn center, by a multi-disciplinary team of surgeons, hand therapists, rehabilitation counselors, and chronic pain specialists.
HotHot--Press Hand InjuriesPress Hand InjuriesDistribution of Cases by Year, n=56Distribution of Cases by Year, n=56
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This slide demonstrates distribution of cases by year, showing a rapid rise in cases in the late 90’s.
•• ageage: : 37.0 years (range 1837.0 years (range 18--62)62)
•• length of staylength of stay: 10.4 days (range 2: 10.4 days (range 2--40) 40)
•• length of followlength of follow--upup: 17.5 months (range 1: 17.5 months (range 1--45)45)
ResultsResultsHotHot--Press Hand InjuriesPress Hand Injuries
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Although patients most commonly presented immediately after their injury, many patients had a significant delay in treatment, with a mean of 8.8 days. 70% of patients required admission, for a length of stay of 10.4 days. Mean length of f/u was 17.5 months, with a range of 1-45 months.
ResultsResultsHotHot--Press Hand InjuriesPress Hand Injuries
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Regarding burn wound characteristics, mean total surface area was 118 cm2. Most burns occurred on the dorsal surface of the non-dominant hand and were full-thickness in depth.
ResultsResultsHotHot--Press Hand InjuriesPress Hand Injuries
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In terms of surgical management, 39/44 patients required operative intervention. Damage control procedures included fasciotomy in 4 pts, digital amputation in 4 pts, and reduction of fracture in 3 pts. 16/39 patients underwent staged excision. Acute coverage was accomplished via STSG in 26 pts, FTSG in 5 pts, groin flap in 7 pts, and completion amp in 1 pt. Flaps required for secondary coverage included an adipofascial turnover flap, a DMCA flap, a posterior interosseous flap, a free lateral arm flap, and a free serratus flap.
ResultsResultsHotHot--Press Hand InjuriesPress Hand Injuries
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In terms of functional morbidity, 68% of patients sustained complications or adverse sequela. This included chronic pain in 14 patients, compressive neuropathy in 11 patients, and soft tissue contractures in 11 patients. Other morbidity included nail plate abnormalities, tenosynovitis, boutonniere deformity, mallet finger, flexor tendon rupture, and unstable joint.
ResultsResultsHotHot--Press Hand InjuriesPress Hand Injuries
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Secondary reconstruction was performed in 50% of patients and included nerve decompression in 11 patients, contracture release in 11 patients, tendon reconstruction in 11 patients, and joint reconstruction in 5 patients.
Critical support from Anesthesia, Physical Medicine, Neurology, Psychiatry, Alternative Medicine
ResultsResultsHotHot--Press Hand InjuriesPress Hand Injuries
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Regarding long-term outcome, function was limited by the following neuro-psychiatric sequelae: nerve compression syndrome in 11 patients, chronic pain in 10 patients, RSD in 4 patients, seizure disorder in 2 patients, PTSD in 9 patients, and mood disorder in 20 patients. Of note, patients received critical support from Anesthesia, Physical Medicine, Neurology, Psychiatry, Clinical Psychology, and Alternative Medicine.
•• all patients compliant with OT/PT all patients compliant with OT/PT
•• return to employmentreturn to employment full-time 14 (25%) restricted/modified 22 (39%) retired 1 (2%) disabled 4 (7%) lost to
follow-up 10 (18%) pending (need FCE, VR) 5 (9%)
ResultsResultsHotHot--Press Hand InjuriesPress Hand Injuries
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All patients were compliant with occupational and physical therapy. Mean final impairment rating was 22%, with a range of 8-84%. Despite this impairment, 64% of patients have returned to full-time or restricted/modified work. 4 patients are disabled 2ary to PTSD, and 10 patients were lost to f/u. 5 cases are still open and dependent upon the results of functional capacity evaluation and vocational rehabilitation testing.
•• early and late complicationsearly and late complications
•• limitations in functional recoverylimitations in functional recovery
•• return to work can occur with return to work can occur with considerable rehabilitationconsiderable rehabilitation
SummarySummaryHotHot--Press Hand InjuriesPress Hand Injuries
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In summary, hot press hand injuries are potentially devastating with significant long-term morbidity. Despite early and late complications and limitations in functional recovery, return to work can occur but requires considerable rehabilitation
Successful rehabilitation dependent uponSuccessful rehabilitation dependent upon::•• Timely referral to an accredited Burn CenterTimely referral to an accredited Burn Center
•• Aggressive Aggressive periperi--operative hand therapyoperative hand therapy
•• Early excision and staged coverage Early excision and staged coverage (groin flap)(groin flap)
ConclusionsConclusionsHotHot--Press Hand InjuriesPress Hand Injuries
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Success of rehabilitation appears to be dependent upon Timely referral to an accredited Burn Center, 2)Aggressive peri-operative hand therapy, 3)Early excision and staged coverage, 4)Secondary reconstruction, 5)Psychosocial support, 6)Multidisciplinary approach Plastic surgeons are uniquely positioned to facilitate the recovery and rehabilitation of these patients.