Case 3: Hand injury: severe burn scar contracture

by nadine on May 30, 2011

Post image for Case 3:  Hand injury:  severe burn scar contracture

History: Over a year ago, this 3 year old boy burned the palm of his hand and fingers.His hand function is now severely limited because his fingers are essentially stuck into the palm of his hand.

Physical Exam: Tight scar tissue connects the fingers into the palm.  The thumb has  some free motion, but all of the other fingers are severely restricted.

 

Treatment options/what was done: This child was brought to the operating room  and the scar tissue connecting the fingers to the palm was cut out (remember to use an upper arm tourniquet so the operative field is bloodless).  This left a large open wound from the palm of the hand onto the base of the proximal phalanges.This wound must be covered with new tissue to prevent recurrence of the contracture.  Because the wound was covered with healthy tissue and there were no exposed tendons, a full thickness skin graft (taken from the child’s abdomen) was used to cover the wound.  After the graft was placed, the hand was put in a splint and wrapped in a bulky dressing for a few weeks.  The splint is critical to stabilize the graft and help the graft to heal. With an adult patient- the dressing would be removed in 5-7 days and the splint reapplied.  It is usually very difficult for a child this young to cooperate and wear a splint, so the dressing is kept in place for a longer period of time.

 

Here is the child’s hand after the dressing was removed. 

 

 

 

 

 

To prevent recurrence of the scar contracture, for the next several months the child (with help from the family) must regularly:

  • do gentle range of motion finger exercises
  • apply moisturizing cream to the graft and do gentle massage.

In addition, a splint is useful to keep the fingers out of the palm during the healing process, but this is challenging for young children.  An alternative may be to create some type of bulky dressing for the child to wear just when sleeping.  If a glove is available, this may serve as a substitute for a splint.  Just be careful taking the glove on and off, so it doesn’t shear the graft.

Corresponding chapters for further information:

    • chapter 12:  skin grafts
    • chapter 28:  hand splinting and general aftercare
    • chapter 34:  hand burns

 

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