58.29 Burnt hands and feet

The thick skin on the palms of a patient’s hands usually protects them, so most burns are on the back. This swells, and as the oedema organizes his hand stiffens. Minimize this oedema by raising his burnt hand. Hang it from a drip pole, as in A, in Fig. 75-1, or put it in a St. John’s sling as in C, in that Figure.

Severely burnt hands are not suited to the exposure treatment because the crust cracks when a patient’s uses his fingers; nor are they well suited to the occlusive method because he cannot exercise his hand inside a big bulky dressing. The plastic bag method is usually best. This keeps his fingers moist and mobile, and makes even a severe burn almost completely painless. Even if both his hands are burnt he can still do many things for himself. An antiseptic in the bag is desirable but not essential. If you use one, you can leave his hand in the bag for more than a day. If you don’t use one you will have to remove his hand and wash it daily.

Recognizing the depth of a burn is difficult in the hand, but is important, because small deep burns may be best treated by immediate excision and grafting (58.17).

Figure 58.26: DISASTERS WITH BURNT HANDS. If the methods described here had been applied almost none of these disabilities and deformities would have occured.

When grafting a burnt hand is needed, graft early, or the patient will lose the function in his hand unnecessarily. His next most urgent need is a splint to prevent contractures, especially if he is a child. The common deformities that can follow are the ’bunch of bananas hand’ B, Fig 58-26, or in its more extreme form the ’claw hand’ shown as E, and F, in this figure. The patient’s wrist extends, his MP joints extend and adduct, and his IP joints flex. Sometimes, his proximal interphalangeal joint is flexed and the distal one extended, producing the boutonniere deformity shown in Fig. 75-22.

If you are aware of the deformities that can happen, you can usually prevent them, by: (1) Splinting a patient’s burnt hand in the position of safety as in A, in Fig. 58-26, and Fig. 75-8. (2) Starting physiotherapy as early as is practical. There is no universal splint for a burnt hand, so consider each patient’s needs separately.

Dynamic (lively) splints are ideal when a patient’s hand starts to recover, so change his fixed splint for one which allows him to move his fingers, but still holds his hand in the best position when it is resting. The easiest way to make a dynamic splint is to make, a plaster cock–up splint, and to fix a piece of thick wire to it as shown in B, Fig. 58-19. Attach rubber bands to the wire and pass these round his proximal phalanges to allow him to exercise his fingers.