University of North Carolina, Chapel Hill, NC, USA.
Purpose: Although some burn centers have reported good initial outcomes for hot-press hand injuries, little is known about the need for secondary reconstruction and the results of rehabilitation. The purpose of this study is to provide a comprehensive, longitudinal, institutional review of hot-press hand burns, focusing on functional recovery and return to work.
Methods: Using a prospectively assembled database, we identified 44 patients with hot-press hand injuries who were treated at an accredited, regional burn center by a multidisciplinary team of burn and plastic surgeons, hand therapists, rehabilitation counselors, and chronic pain specialists. All patients were managed primarily by the plastic surgery service and followed long-term by a single surgeon. Interventions that evolved over the course of the series included peri-operative hand therapy, early staged excision/coverage, lowered threshold for secondary reconstruction, and subspecialty referral. Outcome measures included length of stay, complications, need for late reconstruction, final impairment ratings, and return to work.
Results: From December 1994 to November 2004, we managed 44 patients (mean age, 37.1 years; 33 females, 11 males) with hot-press hand burns (10 partial thickness, 34 full thickness; mean surface area 123 cm2). Mechanism of injury included dry-cleaning press (n=32), industrial press (n=9), home appliance (n=2), and steam press (n=1). Operative intervention was required in 39/44 patients (88.6%). Initial “damage control” procedures included excisional debridement (n=39), fasciotomy (n=4), digital amputation (n=4), and fracture reduction/fixation (n=3). Resurfacing was staged in 16/39 patients (41%) and included STSG (n=26), groin flap (n=7), FTSG (n=5), and completion amputation (n=1). Mean length of stay was 10.6 days. Significant functional morbidity was observed in 29/44 patients (65.9%) and included peripheral nerve compression (n=11), neosyndactyly (n=8), boutonniere deformity (n=5), stenosing tenosynovitis (n=4), mallet finger (n=2), and late tendon rupture (n=1). Secondary reconstruction was performed in 25/44 patients (56.8%) and included carpal tunnel release (n=8), digital neurolysis (n=4), cubital tunnel release (n=2), Guyon’s canal release (n=2), and digital nerve graft (n=1); neosyndactyly release (n=8); tenolysis (n=5), tendon repair (n=3), and tendon transfer (n=2); and capsulotomy (n=3) and arthrodesis (n=2). Tissue needed for secondary reconstruction included a free serratus flap, a free lateral arm flap, a volar forearm adipofascial turnover flap, and a reverse posterior interosseous fasciocutaneous flap. Regarding long-term outcome, function was limited by the following neuropsychiatric sequelae: chronic regional pain syndrome (n=10), reflex sympathetic dystrophy (n=4), and post-traumatic stress disorder (PTSD) (n=7). Mean final impairment rating for the hand was 20% (range 8-60%). Despite this impairment, 24/44 patients (54.5%) have returned to work (9 full duty, 15 restricted/modified), with 4 patients disabled secondary to PTSD, 11 cases pending, and 5 cases unknown. Mean follow-up was 17.2 months (range: 1-45 months).
Conclusions: Hot-press hand burns are a potentially devastating injury with significant long-term morbidity. Functional recovery and return to work are critically dependent upon a multidisciplinary approach, which incorporates aggressive hand therapy, early staged excision/coverage, secondary reconstruction (specifically nerve decompression), and psycho-social support. Plastic surgeons are uniquely positioned to facilitate the recovery and rehabilitation of these patients.