Brlures de la main

burns 33 (200

Christian Dumontier & Francesco Brunelli

Centre de la Main, Guadeloupe &
Institut de la Main, Paris (et Brescia)
Avec laide de Rmi Foissac (Nice) et du service des brls de Marseille

Bibliographie
Richards, Acute surgical management
of hand burns. JHS Am 2014;39(10):
2075-2085

(sur le site)

Kamoltz, The treatment of hand

burns. Burns 2009; 35: 327-337

(sur le site)

Germann, The burned hand. Greens

operative textbook, pp2159-2190

Dfinition

Temp. < 44C : pas de lsion

Temp. = 44C : quilibre instable, lsions
en cas dexposition prolonge (plusieurs H)
44C < temp. < 51C : les lsions cellulaires
doubles pour chaque degr
Temp. > 51C : destruction trs rapide
Temps. > 60C : coagulation immdiate des
protines

Brlure : destruction immdiate totale ou

partielle de la peau (et parfois des tissus sousjacents), le plus souvent dorigine thermique.
Problmatique : perte des fonctions de
protection mcanique et immunologique de la
peau, altration de la thermorgulation
La brlure est un traumatisme initialement local (plaie)
avec des consquences gnrales (troubles de lhomostasie);
elle volue avec le temps

La peau
Epiderme: 0,05 1,5 mm
pithlium pluristratifi avec
des Annexes cutans,
Rle immunologique fort,
Epaisseur variable,
Derme: 0,3 3 mm

Surgical Technique

Pigmentation variable

Superficiel ou papillaire,
Profond ou rticulaire,

FIGURE 1: A cartoon representing the structure of intact skin. Notice the dermal capillary bed and
nently in differentiating second- and third-degree burns. Also note the epithelial lining of the hair foll
for rapid healing of supercial burns. (Reprinted with permission from Duffy BJ, McLaughlin PM, Ei
and early management of burns in children. Clinical Pediatric Emergency Medicine. 7(2):82e93. C

Peu immunogne,
Vaisseaux et nerfs
Hypoderme:
Stockage nergtique, Isolation
Thermique, Rle Esthtique

La brlure
est une
lsion
dynamique
Une lsion centrale, dtruite
Entoure dune zone de stase qui peut cicatriser si les
conditions sont runies (pas dhypovolmie, dinfection,...)
Une zone externe dhyperhmie, de vasodilation
Les limites entre ces zones sont variables et peuvent varier
selon les conditions locales, gnrales et le traitement

Le feu est connu depuis longtemps

(source wikipedia)

Atteste partir denviron -350000ans, (sites de

Menez Dregan Plouhinec, de Bilzingsleben en
Allemagne ou de Vrtesszls en Hongrie et plus
rcemment de Terra Amata prs de Nice).
Une quipe fait remonter les plus anciennes traces
de la domestication du feu -790000ans sur le
site du Gesher Benot Ya'aqov au bord du Jourdain .
1

Le rle du feu
L'anthropologue Polly Wiessner a valu l'activit nocturne et diurne
des Bushmen du Kalahari. La majorit des conversations le jour
portent sur des questions conomiques (stratgies de chasse et de
cueillette, fabrication d'outils), des critiques, des plaisanteries et des
commrages (6% du temps tant seulement consacr raconter des
histoires) alors que la nuit autour du feu, plus de 80% des
conversations sont des contes, souvent au sujet de personnes
distantes ou du monde des esprits.
Selon Wiessner, la domestication du feu par les chasseurs-cueilleurs a
permis l'allongement du temps de veille, la vie nocturne centre sur
la runion autour du foyer favorisant les interactions sociales et
l'mergence des cultures prhumaines par le chant, la danse ou le fait
de raconter des histoires et lgendes

Bref rappel historique

Egyptiens: gomme, lait de chvre, lait de femme
enceinte, argile, excrments et poils danimaux
Hippocrate: Irrigation leau froide, graisse,
poudre vgtale, tranches doignon,...
Dupuytren: Premire classification dtaille (6
stades)
Diffenbach (1792-1847): 1re greffes dermopidermiques

Epidmiologie

Les brlures sont des accidents graves et des urgences

Mortalit (%)
Detresse respiratoire aigue

34,1

Dfaillance polyviscrale

26,8

Infection

13,2

Brlures

8,6

Infarctus

2,3

Accidents vasculaires crbraux

3,1

Autres

11,9

Mortalit hospitalire 38 % chez > 60 ans

Importance dune ranimation hydro-lectrolytique
initiale adquate (mortalit 30 % vs 70 %)
Cutillas M, Burn 1998

Epidmiologie
3 -8 brlures / 1000 habitants (150,000 400,000
nouveaux cas/ an en France)
10,000 hospitalisations dont un tiers en centre
spcialis, 1000 dcs (Source DHOS 2005)
Mortalit 1,66 /100,000 personnes / an (1000 dcs)
Facteurs pronostiques :
surface brle et ge

pidmiologie Population
Enfants de 0 4 ans : 19,7 %
Enfants de 5 14 ans : 9,3 %
Adultes de 15 24 ans : 14,5 %
Adultes de 25 44 ans : 32,7 %
Adultes de 45 64 ans : 15,8 %
Adultes > 65 ans : 8,1 %

Epidmiologie
- causes
Accidents
domestiques: 65%
Accidents de
travail: 18%
Feux: 5%
AVP: 4%
Agression: 2%

Ambulatoires Hospitaliss

Flammes

29

59

Liquides

47

25

Contact

Chimique

Electrique

12

Dure et temprature: 1h 45C, 1mn

50C, 1s 70C

Epidmiologie aux carabes

2,3 / 100,000 habitants hospitaliss pour
brlures
30% ont entre 0 et 4 ans
Taille brlure: 13,6% (0,5 - 80%)
Liquide bouillant (48%), flammes (22%)
3,3% de dcs, 16 jours dhospitalisation
Frans FA et al. The epidemiology of burns in a medical center
in the caribbean. Burns 2008;34:1142-1148

Principes gnraux

Gravit des brlures

La gravit de la brlure dpend de sa localisation, de

sa profondeur, de ltendue de la surface endommage et
de l'agent causal, mais aussi de la qualit des soins initiaux et
du terrain
Toutes les brlures touchant plus de 20% de la
surface corporelle ncessitent une ranimation ++++
Il y a 30 ans, survie exceptionnelle si 50% SCT,
Actuel: 50% de survie avec 80% SCT [Indice de Baux: SCT + ge +
tare= 15%]

Unit Burn standard: SCB + (3 x % brl. 3e degr).

Grave si > 50; Mortalit 100 % si > 150.

Diagnostic de Gravit

Surface brle: rgle des 9

Profondeur: 3 degrs
Facteurs aggravants
Type de brlure:
Localisation :
Terrain :
Lsions associes :
Classification

Surface: rgle des 9 de Wallace (adulte) en

liminant les brlures du 1er degr
Tte = 9%
Membre suprieur = 9% (X2)
Membre infrieur = 18% (X2)
Face antrieure du tronc = 18%
Face postrieure du tronc =
18%
Organe gnitaux = 1%
1%

Pour les zones dissmines, se rappeler que la face palmaire de la

main reprsente 1% de la surface corporelle quelque soit lge.

Cette rgle varie en fonction de lge

Chez lenfant, utiliser les

tables de Lund et Browder

La profondeur
Beaucoup plus
difficile valuer +++
La brlure volue
dans le temps,
lvaluation est donc
rpte
Elle est variable sur
une surface brle

Exemple

1er degr
2me, superficiel
2me, profond
3me degr

Profondeur
1er degr
2me degr
superficiel
2me degr
profond
3me degr

Superficielle

Intermdiaire

Intermdiaire

Profonde

Cicatrisation sans squelles

Cicatrisation < 10 jours (rares

squelles)
Cicatrisation > 10 jours ET
squelles
Pas de cicatrisation
spontane possible

1er degr/ Superficielle

Erythme douloureux
Gurison sans
cicatrice en 4 5
jours
Desquamation

2me degr superficiel / intermdiaire

Phlyctnes paroi paisse,

suintantes
Fond rose ou rouge qui
blanchit la palpation
(capillaires prservs)
Douleurs intenses et
douleur au toucher lger
(rcepteurs sensitifs intacts)
Gurison 10/14 jours avec
dyschromie possible

2me degr profond / intermdiaire

Lsion typique des liquides

bouillants - Phlyctnes
inconstants
Surface blanchtre ou rose ple
Diminution de la sensibilit au
toucher
Absence de blanchiment/
recoloration la pression
Phanres non adhrents (poils)
Cicatrisation en 4-6 semaines si
il reste des annexes et en
labsence dinfection mais les
squelles sont obligatoires

Le deuxime degr profond cicatrise

lentement (> 21 jours) et laisse des
ranons cicatricielles majeures

Hypertrophie > 80%

Rtraction

Le 2me degr profond doit

tre trait comme le 3me +++

Diagnostic clinique difficile

Pape, 2001 70%
Jeng, 2003 71%
Holland, 2002 66%

La diffrence entre superficiel et profond

est souvent difficile

Facile

Difficile

Superficiel

Profond

Ce dautant que la brlure

est une lsion volutive

J3

J8

J 0

J30

Brlure de la main par caramel: Superficiel ou Profond ?

ACUTE SURGICAL MANAGEMENT OF HAND BURNS

Surface sche,

dure, escarriforme
Ple ou carbonise

Vaisseaux

thromboss visibles

Indolore au

toucher

FIGURE 4: Third- and fourth-degree burns on a hand. A The skin is leathery, discolored, an
constricting circumferential burn. B The repose of the resting ngers suggests burn injur
(transverse arrow, ngers extended) and coagulation of the forearm muscles (oblique arrow

FIGURE 3: Examples of deep second-degree burns. A A step-off is present between the wou
sloughing serum and cream cover a pale wound bed with hemorrhage in the dermis.

3me degr / profond

28% was third-degree. Associated injuries were frequent: 66% inhalation, 33% multiple
injuries. Eight of the 9 cases (88%) were life-threatening (Abbreviated Burn Severity Index
score > 8).
The forearm and arm were burnt on the homolateral side in 9 cases (82%) and also
on the contralateral side in 7 cases (63%). The dominant hand was burnt in 7 cases, and
in 10 cases (90%) circular deep injuries justified escharotomy. In 2 cases, crush injury was
associated with the burn (cases 1 and 4) (Fig 2).
In 55% of the cases, excision was performed between day 3 and day 5, followed
by coverage by artificial dermis (containing bovine collagen) in most cases, or by thin
skin autograft, which proved to be a failure. In 3 cases, multiple distal amputations were
performed before conducting flap surgery. In 5 other cases, the nail bed of each finger

Figure 2. Clinical case 1. (a) Burn to dorsal face of

5 fingers including metacarpophalangeal. (b) Amputation trans second phalanx and proximal interphalangeal
arthrodesis after debridement. (c) Appearance before
release of fingers. (d) Appearance of flap after separation of fingers. (e and f) Plastic and functional results
after toe-to-thumb transfer. (g) Appearance of donor
site.

Carbonisation

La face ou le cou : risque dasphyxie,

les organes gnitaux externes : risque
septique, possibilit d'obstruction des
voies urinaires ncessitant la mise en
place d'une sonde urinaire,
Les zones priarticulaires : risque
d'apparition de cicatrices rtractiles
dans les plis de flexion,
Les zones orificielles: rtraction
les extrmits : risque d'atteinte
fonctionnelle.
Les brlures de la moiti infrieure du
corps sont souvent plus graves car elles
gnent le nursing et touchent les
meilleurs zones de prlvement cutan.

Localisation

Agent causal, terrain et qualit des

soins initiaux
Le sexe (Mortalit un peu plus
leve chez les femmes)
Les maladies pr-existantes
La cause de la brlure: Suicide;
mortalit est plus leve par
combustion de vtements que
liquide bouillant
Le dlai entre l'accident et
l'admission dans un centre
spcialis, la mauvaise prise en
charge initiale
Les complications qui surviennent
au cours de l'hospitalisation (Sd
de loges, infection)

Consquences: Burn injury

severity grading system
Mineures : <10% SCT chez ladulte( 10 50 ans), <5% aux
ges extrmes, <2% pour une carbonisation Ambulatoire
Modres : 10 20% adulte ( 5 10% enfant, sujet g),
2 5% carbonisation, Haut voltage, Inhalation suspecte,
Brlure circonfrentielle, Problme mdical associ
Hospitalisation
Majeure: >20% adulte, 10% enfant et sujet g, >5%
carbonisation, Brlure lectrique, Brlure face, il,
oreille, OGE, articulations, Polytraumatiss
Hospitalisation en centre de brls

Cas particuliers des brlures de la main:

Une tude sur deux ans de 568 brlures
89% avaient une brlure dun ou des
deux membres suprieurs
Brlures thermiques 48% (main 40%)
Brlures lectriques (main 70%)

Traitement des brlures de la main

Priorit la Survie = Ranimation

(Protocoles +++)
Ne pas oublier: SAT/VAT,
environnement chaud

Prise en charge pr-hospitalire

Appel des secours
Refroidissement de la brlure par de leau tide
pendant 15 minutes ou des gels deau en se mfiant de
lhypothermie (dans les 15 premires minutes, 15
minutes sous de leau 15)
Retrait des vtements sils ne collent pas
Retrait des bagues et alliances
Couverture des zones brles (lutter contre le froid)

Allison K, Injury 2004

Prise en charge mdicale:

Principes du traitement
En urgence:
Permettre la survie vasculaire: escarrotomie ?
Eviter laggravation
Dans les premiers jours:
Lutter contre la rtraction: pansements, attelles,
rducation
Prise en charge de la plaie (quotidien puis bi-quotidien)
Le traitement des squelles:
Chirurgie plastique/reconstructrice de la main brle

Rsultats du traitement

Brlures superficielles: 97% de bons

rsultats
Brlures profondes/partielles: 81%
de bons rsultats

En urgence: brlures de la main

Refroidir (pas glacer 15 c, 20 mn)
Calmer la douleur (Morphine)
Pas dantibiothrapie systmatique
Surlever le membre
Oedme = limitation de la mobilit = enraidissement
Apprcier la vascularisation distale dans les brlures
circulaires
Doppler / clinique (doigts raides, douloureux, tendus,..)
Au moindre doute: escarrotomie (sans anesthsie ou
locale). Un hmi-cot puis lautre si ncessaire. Ne pas
oublier les interosseux (fasciotomie). Dpasser la zone
brle.

Figure 61-6 A,

Figure 61-6 A, Schematic illustration of escharotomy incisions in the upper

dorsum of the hand. C, Clinical situation after escharotomy of the dorsum o
Figure 61-6 A, Schematic illustration of escharotomy incisions in the upper extremity. B, Escharotomydigits.
incisions at the

dorsum of the hand. C, Clinical situation after escharotomy of the dorsum of the hand. D, Escharotomy incisions in the
digits.

Lescarrotomie
multiplie par
4 la survie
des doigts

Escharotomie
aponvrotomie
Si atteinte du
muscle (brlures
lectriques ou trs
profondes)

osition for the hand.

Attelles +++
21/02/09 23:36

Figure 61-7 Ideal splinting position for the hand.

Indispensable dans les grandes brlures

Prcocement (J1) + Kin si possible
Position intrinsque plus (lutter contre
extension MP = point de dpart)

Mobilisation prcoce
Lutter contre la
tendance
lenraidissement +++
Orthse + Kin +
participation du
patient vigile

La prise en charge de la plaie

Nettoyage et dbridement +++
CAT phlyctnes ?
laisser les petites phlyctnes, entraine moins
dinfection, et moins de douleurs (swain BMJ 1987)
Exciser les grandes phlyctnes (liquide riche en
facteurs pro-inflammatoires nocifs pour la brlure)
Le traitement dpend ensuite de la profondeur des
lsions mais les pansements doivent tre indolores,
atraumatiques (pansement non adhrent), Antiseptiques
incolores et non alcooliss

Lsions superficielles localises

Mettre une pommade grasse

(Flammazine, Biafine, Bepanthne,)
Pas de pansements
Mobilisation immdiate

alone and debride dorsal hand blisters. The claimed advantage of leaving blisters alone is tha
provides an autogenous burn dressing. The rationale for not debriding palmar blisters is that
specialized and difficult to replace with graft. The rationale for debriding all blisters is that blis
high levels of thromboxane B2 and prostaglandin E2 .[3,4] Prospective studies demonstrating
method over another are lacking. The authors' practice is to debride all blisters, assuming tha
would likely rupture the blisters and provide a possible portal of infection.

Lsions superficielles tendues

Daily Care
Cleansing

Burned hands should be cleansed twice daily with a mixture of water and chlorhexidine gluco
clearly partial thickness may be managed with one-percent silver sulfadiazine cream. Indeter
placed in alternating agents, which include mafenide acetate 11-percent cream during the da
sulfadiazine cream at night. Burns that are obviously full thickness or potentially infected are
daily mafenide acetate.

Pansements vaselins
(Flammazine)

Dressings

A number of dressings are available for the treatment of clean partial-thickness burns. Porcin
is inexpensive, but becomes inelastic once applied, hindering hand and finger motion. Allogra
skin) provides an excellent temporary dressing but is too expensive for routine use. Biobrane
dressing (Bertek Pharmaceuticals, Morgantown, West Virginia) is a bilayer semisynthetic dres
elastic nylon fabric bonded to a semi-permeable silastic membrane and coated with collagen
manufactured from this material are available in a variety of sizes and are ideal dressings for
thickness burns of the hands (Figure 1). The gloves can be applied in the emergency depart
monitored daily on an outpatient basis. Nonadherence of the dressing indicates the possibility
the burn is full thickness. In the case of infection, the dressing should be removed, and topic
placed. The gloves are flexible, facilitating hand therapy, and are less painful than daily wash
topical creams. The dressing material lifts off the burn wound, as epithelialization proceeds, a
scissors.

Mettre la main dans un

gant chirurgical, un sac,
permettant la mobilisation

Rducation prcoce et
orthses de positionnement

Lsions profondes localises

JBUR-2897; No of Pages 11

burns xxx

Excision sous garrot

Greffe en peau pleine
Bourdonnet 8 jours
Main dans une orthse

Fig. 2 Custom made compression glove with an additional

compression topcoat for the web spaces (by courtesy of
ThuasneW).

the donor site. A newer technique is described by Donelan and

Garcia [80].

Severe postburn skin losses

Posterior interosseous flap

Severe postburn skin losses

Posterior interosseous flap

Very severe postburn skin losses

(scapular flap)

Lsions Intermdiaires:
Conservateur ou Reconstruction ?
Surtout dos de la main
Lutter contre la douleur et linfection
Pansements gras +/- ions argent
(Flamazine)
A changer 1 fois / jour (plus si
suintement important)
Essayer de laisser les doigts indpendants
(rducation)
Il faut 2/3 jours pour juger de la profondeur

al Technique

FIGURE 1: A cartoon representing the structure of intact skin. Notice the dermal capillary bed and nerve endings, which gur
nently in differentiating second- and third-degree burns. Also note the epithelial lining of the hair follicles and sweat glands, whi
for rapid healing of supercial burns. (Reprinted with permission from Duffy BJ, McLaughlin PM, Eichelberger MR. Assessmen
and early management of burns in children. Clinical Pediatric Emergency Medicine. 7(2):82e93. Copyright ! 2006 Elsevier,

TTT conservateur
Plus sur (manque
dexprience)
Mettre la main dans un
gant avec un agent
antibactrien

FIGURE 2: A supercial second-degree hand burn. A The wound bed is moist and painful and blanches when compressed
blisters have been removed and the wound bed is bleeding after minor debridement.

skin is naturally hairless and covers the palms and

soles (Fig. 1).
Recognition of burn depth is exceptionally difcult. Unevenness in burn injuries, skin pigmentation,
discoloration from soot, adherent clothing, blisters,

dressings, and topical treatments all chan

appearance of burn wounds, confounding the
rate identication of burn depth. In addition
wounds tend to progress and demarcate over
48 hours, adding uncertainty to the initial eval

Rducation immdiate

J Hand Surg Am.

Vol. 39, October 2014

l
,
l

o
t
a
e
,

)
m

TTT conservateur
Cicatrisation > 3 semaines,
cicatrices hypertrophiques invitables
Mettre des gants compressifs/
feuilles de silicone ds que possible
+++
(2009) 7074

71

Excision tangentielle prcoce

Ncessite beaucoup
dexprience mais prfre la
main
Avant le 5me jour (infection),
sous garrot
Au dermatome mince/ Aller
jusquen zone saignante /
tamponner avec des ponges
lpinphrine
Greffe peau mince surtout

Autre possibilit dexcision: Le Versajet

Atteinte bilatrale, excision-greffe main

droite, Conservateur gauche

Excision prcoce > pansements rpts (pas

de diffrence dans les sries comparatives)
A faire avant J5 tant que la plaie est
strile

Dlai avant la greffe ?

Several articles report no difference in
the outcome of late versus early excision
of hand burns provided one continues
therapy by means of judicious functional
orthosis fabrication and maintaining
range of motion (ROM) to wrist and
fingers.
Omar MT, Hassan AA. Evaluation of hand function after early excision and skin grafting of
burns versus delayed skin grafting: a randomized clinical trial. Burns. 2011;37(4):707e713.
Mohammadi AA, Bakhshaeekia AR, Marzban S, et al. Early excision and skin grafting versus
delayed skin grafting in deep hand burns (a randomized clinical controlled trial). Burns.
2011;37(1):36e41.

Quel type de couverture ?

Peau pleine si possible (petites
zones)

FIGURE 11: Example of the use of a dermal substitute. A At this stage, the Integra (In
on the wound bed as evidenced by the red color of the material. B After removing the s
we applied an STSG.

TABLE 1. Dermal Substitutes and Burn-Specic Wound Dressings W

Primary Uses, and Company Information
Skin
Substitute

Peau mince > peau mince

perfore
Substituts cutans (Biobrane,
Suprathel) sont onreux et
rservs aux centres spcialiss
Substituts dermiques (integra/
Matriderm) sont plus utiliss en
secondaire (risque infectieux)

Components

Primary Use

Xenograft

Porcine Skin

Supercial second-degree burns

temporary covering

Biobrane

Nylon mesh, silicone, and

type 1 porcine collagen

Supercial second-degree burns

temporary covering

Allograft

Full-thickness
cadaver skin

Deep second- and third-degree burns

temporary covering

AlloDerm

Cadaver dermis

Third-degree burns combined with

thin STSG. Wound closure

Integra

Silicone, collagen,
chondroitin-6-sulfate

Third-degree burns combined with

thin STSG. Wound closure.
Two-stage procedure

Matriderm

Collagen, elastin

Third-degree burns combined with

thin STSG. Wound closure

Oasis

Porcine small intestinal

submucosa

Second degree burns as a dressing.

Wound closure

Primatrix

Fetal bovine dermis

Second- and third-degree burns,

may be combined
with STSG. Wound closure

Xenograft (pigskin) (Brennen Medical, LLC, St.

Paul, MN) covers supercial second-degree burns. It
seals the wound from the environment, allowing it to
epithelialize. Allograft, cadaver skin (AlloSource,
Centennial, CO), is useful in the management of large
J Hand Surg Am.

burn injuries
possible and
dressing. All
fashion simil
the cadaver

Vol. 39, October 20

mising. A good alternative is the arthrodesis of the joint in

ctional position. Functionally inhibiting defective positions
he distal joints are rare but can be corrected by arthrodesis
ecessary.

In large and thick scars which cause a hyperextension of

the MCP joints, excision of the scar with subsequent skin
grafting is required. In case of the fact that a resection of the
scarred and contracted subcutaneous tissue is required,

Fig. 1 a Deep hand burn (deep dermal and full-thickness) prior to surgery; (b) early result after a single step
(MatridermW and split thickness skin graft); (c) long-term result (1 year after surgery) after single step recon
compression
therapy;
(d) skin
elasticity.
Fig.
1 a Deep hand
burn (deep
dermal
and full-thickness) prior to surgery; (b) early result after a single step reconstructi

(MatridermW and split thickness skin graft); (c) long-term result (1 year after surgery) after single step reconstruction an
compression therapy; (d) skin elasticity.

Reconstruction en un temps avec Matriderm (Kamolz, Burns, 2008)

Please cite this article in press as: Kamolz L-P, et al. The treatment of hand burns. Burns (2008), doi:10.1016/j.burn

ACUTE SURGICAL MANAGEMENT OF HAND BURNS

2081

FIGURE 11: Example of the use of a dermal substitute. A At this stage, the Integra (Integra Life Sciences, Plainsboro, NJ) has engrafted
on the wound bed as evidenced by the red color of the material. B After removing the silicone layer and light debridement of the wound,
we applied an STSG.

TABLE 1. Dermal Substitutes and Burn-Specic Wound Dressings With a Description of Their Components,
Primary Uses, and Company Information

Xenogreffes
2079

FIGURE 7: A deep second-degree burn after 2 weeks under Xenograft (pigskin; Brennen Medical, LLC, St. Paul, MN). The wound had
not completely healed and required excision and grafting. A Before debridement. B After debridement with the Versajet and hemostasis
with electrocautery. We removed small nests of epithelial cells (arrow in A shows small healed area that was removed for uniform
coverage) from the center of the wound to provide a uniform wound bed for grafting (arrow in B shows uniform wound bed).

Surgical Technique

ACUTE SURGICAL MANAGEMENT OF HAND BURNS

Xenogreffes

FIGURE 5: A Weck knife (Teleex Medical, Research Triangle Park, NY) used at our institution. This knife has a straight razor blade
and multiple xed guards ranging from 0.004 to 0.012 inch in depth. A Blade and knife handle separate. B Blade inserted into handle
and guard in place for right-handed use.

Surgical Technique
FIGURE 6: A deep-second and third-degree burn wound before A and after B surgical debridement. Note the pink moist wound bed with
punctate hemorrhage. Arrows show hemorrhage. Electrocautery was used on the larger bleeding capillaries prior to applying an STSG.
Arrows also show sites to cauterize.

burns that heal with time and topical antimicrobials

avoid a donor site and the scarring associated with

late versus early excision of hand burns provided one

continues therapy by means of judicious functional

PRADIER ET AL

PRADIER ET AL

PRADIER ET AL
Figure 2. Clinical case 1. (a) Burn to dorsal face of Figure 2. Continued
Figure 1. Surgical technique. (a) After excision of necrotic tissue and splinting
of the
5 fingers including metacarpophalangeal. (b) Amputaextended fingers with Kirschner wire, the hand was placed in the subcutaneous pocket. (b)
JOURNAL OF BURNS AND WOUNDS
VOLUME 6 PRADIER ET AL
tion trans second phalanx and proximal interphalangeal
The hand was immobilized, and the fingers were separated with an external fixation. (c)
exposed joints
arthrodesis after debridement. (c) 7Appearance
beforerequired flap coverage. In 36% of cases, a posterior interosseous flap was
After 3 weeks, the hand was cut free from the abdominal wall. The donor site was covered
used
complement
coverage of the thumb (Fig 3). The fingers were covered in 10 of 11
release of fingers. (d) Appearance of
flaptoafter
separawith an autograft. (d) The interdigital webs were separated at the same time, or 2 weeks
(Fig 4),
the dorsum in 4, the thumb in 3, and the wrist in 1 case. The mean area
tion of fingers. (e and f) Plastic andcases
functional
results
2
2
later, and the Kirschner wires were withdrawn 10 days later.
covered was
92.8 cm (range: 45160 cm ). In all cases, the donor site was chosen on the
after toe-to-thumb transfer. (g) Appearance
of donor
homolateral side: the abdomen in 6 cases, the side in 3 cases, and the root of the thigh in the
site.

last case (Fig 5). The donor site was closed using a thin skin graft in all but one case. The
drained by a multitube drain or corrugated silicone drainage sheet (delbet). To ensure
gree. Associated injuries were frequent:
inhalation,
33% multiple
pedicle 66%
was severed
on average
on day 31, and the mean number of surgical interventions,
flap adherence, the hand was firmly held in position by elbow support using bands. The
he 9 cases (88%) were life-threatening
(Abbreviated
Burn Severity
pocket
flap-graft included,
was 3,Index
that is, on average the pedicle was severed in 2 stages.
pedicle was severed from the third week, in 3 steps. Interdigit webs were sectioned along
All flaps were viable (including 8 cases of 100% survival), even though 3 complications
and arm were burnt on the homolateral
side palm
in 9 cases
and also
arose. The
of the(82%)
hand and/or
the lateral faces of the burnt fingers were also covered
the bisecting line, up to the web space arc. Excess web tissue was removed, except for the
al side in 7 cases (63%). The dominant
hand
was burnt
and
by a skin
autograft
in 8inof79 cases,
cases (89%).
dermis, which was sutured to the lateral faces of the fingers.
circular deep injuries justified escharotomy. In 2 cases, crush injury was
e burn (cases 1 and 4) (Fig 2).
Secondary phase
he cases, excision was performed between day 3 and day 5, followed
RESULTS
tificial dermis (containing bovineThe
collagen)
in were
most examined
cases, or on
by average
thin
8 patients
30 months (range: 578 months) after the injury
ich proved to be a failure. In 3 cases,
multiple
were
(Table
2). Thedistal
meanamputations
length of stay
in the rehabilitation center was 5.1 months, excluding
Over
conducting flap surgery. In 5 other
cases,
the
nail
bed
of
each
finger
the patient who was still at the center at the time of the follow-up examination (Fig 5).
Spathe last 6 years, we have treated 9 patients (6 men, 3 women; mean age 29.5 years)
by
ated. The nail beds were preservedtherapy
in a single
7). On(range:
average,
washand
done(case
1.3 times
01.7) a year on average. The 6 patients who werethe
no pocket flap-graft technique, among the 1046 patients hospitalized in our department

(about half presented with acute second- and third-degree burns to the hands). In 2 cases,
the two
9 hands were operated on simultaneously, that is, a total of 11 hands. One female
patient died 30 days after suffering the burn injury, that is, 24 days after surgery. Eight
patients were followed up (9 hands treated surgically). The last patient of the series was still
in the rehabilitation center at the time of the follow-up consultation.
Acute phase

Figure 3. Continued

Pradier, J Burns & wounds, 2007

Figure 2. Continued

Figure 2. Continued

In all cases, thermal injury was caused by flames, except for one case of burn by contact
with hot
metal
iron)of(Table
1). On
average,(graded
36% of
the hand
surface
was burnt, of which
There
were(an
3 cases
web space
contracture
C1C4),
2 cases
of digit-palm

longer wearing compression gloves at the time of the examination had worn them for a
15
mean period of 13.3 months (range: 524 months). contracture affecting the little finger, 2 cases of digit-palm contracture affecting all the
andlater)
one boutonni`
ere deformity.
Surgical interventions during the sequelae (more fingers,
than a year
were performed
in 5

JOURNAL OF BURNS AND WOUNDS

PRADIER ET AL
JOURNAL OF BURNS AND WOUNDS

VOLUME 6

Figure 4. Clinical case 6. (a) Deep burn to distal part of 4 fingers of increasing
severity toward cubital fingers, following prolonged contact with a hot iron
during an epileptic attack. (b) Appearance after debridement. Note extent of
joint destruction. (c) Defatted pocket-flap on abdomen. (d) Appearance after
separation of fingers. (e) Appearance of hand at
6 months,
without alteration.
PRADIER
ET AL
(f) Appearance of donor site.

19

Figure 4. Clinical case 6. (a) Deep burn to distal part of 4 fingers of increasing
severity toward cubital fingers, following prolonged contact with a hot iron
during an epileptic attack. (b) Appearance after debridement. Note extent of
joint destruction. (c) Defatted pocket-flap on abdomen. (d) Appearance after
separation of fingers. (e) Appearance of hand at 6 months, without alteration.
(f) Appearance of donor site.
Figure 4. Continued

Figure 4. Continued

Figure 2. Continued
19

20

20

Pradier, J Burns & wounds, 2007

VOLUME 6

Cas Particuliers

Brlures lectriques

Brlures lectriques
Le courant domestiques
donne des lsions
localises et profondes
mais pas de diffusion
Le courant de haut
voltage (> 1000 V)
entrane des lsions par
arc lectrique ET
diffusion

Brlures lectriques
La chaleur dgage par
le passage du courant
dpend
De la rsistance des
tissus
De la dure du contact
Du carr du voltage

Los conduit mal (il chauffe et lse

les tissus alentours = muscles)

Brlures lectriques

Le risque immdiat est : musculaire,

cardiaque (ECG), rnal (hyperkalimie,
myoglobinurie), neurologique.
Rhabdomyolyse frquente avec risque
IRA. Corrlation entre CPK et devenir.
Adaptation des apports hydrolectrolytiques avec majoration de 50 %

Brlures lectriques
Les lsions localises sont
traites par excision-greffe
prcoce
Fasciotomie +++ risque de
syndrome de loge
Lutilisation du VAC a
chang la prise en charge +++
Couverture prcoce par
lambeaux des structures
nobles

Cas particuliers

Brlures chimiques

Trois groupes de brlures

chimiques
Civiles: se mfier des suicides
Industrielles: potentiellement graves,
soins bien organises
Guerre: lsions associes
De faon gnrale: cicatrisent moins bien et
ncessitent plus dinterventions
Reprsentent 3% des brlures et 30% des
dcs

Physiopathologie: la brlure
continue tant que le
produit nest pas retir +++
Type de produit chimique
Surface de contact
Concentration du produit
Dure de contact

LAVAGE

Traitement initial
Zone de contact (peau palmaire plus rsistante)

Brlures chimiques
tendue faible
Gravit locale : estimation
de la profondeur difficile
Enlever les vtements
Identifier lagent responsable
Rechercher une toxicit
systmique

Brlures chimiques
Brlure par base :

Brlure par acide :

Physiopathologie :
ncrose, production
de chaleur,
saponification,
dessiccation

Physiopathologie :

Retirer la poudre ou
les particules
restantes

lacide fluorhydrique

Laver abondamment

Laver abondamment

dnaturation
protique, production
de chaleur
Cas particulier de
avec risque
dhypocalcmie

Brlure par acide sulfurique

Brlures chimiques

Laver, laver , laver leau +++ > 1-2 heures

le phnol est retir avec du glycrol
Le phosphore est neutralis avec du sulfate
de cuivre
Acide hydrofluorique:

Risque ltal par hypocalcmie

si brlures de plus de 2% de la surface

corporelle.Traitement spcifique local :Gluconate de
calcium 10% sous cutan (0,5 ml/cm SB),Gel de gluconate
de calcium 2,5% et

une excision prcoce

Le reste du traitement suit les mmes rgles

Une brlure
chimique
iatrogne: Le
Dakin en
traitement dun
panaris

Brlures par irradiation

600 cas rpertoris depuis 1945
conduisant 145 dcs (source IRSN)

Source: IRSN

Consquences des irradiations aigus

Aux trs fortes doses (> 2050 Gy) le systme nerveux
est touch; dsorientation, ataxie, dlire, coma,
convulsions, puis mort surviennent quelques minutes
quelques heures aprs l'exposition.
Pour des doses moindres (120 Gy), le syndrome se
droule en trois phases:
Une phase prodromique, non mortelle, dbute entre
quelques minutes et quelques heures aprs
l'exposition et dure au plus quelques jours, avec, en
fonction de l'intensit de l'exposition: fatigue,
cphale (mal de tte), nause et/ou vomissements,
rythme (rougeurs de peau);
Une priode de latence de quelques jours deux
semaines
Une phase aigu, potentiellement mortelle, dure un
mois deux ans, avec des problmes hmatologiques,
gastro-intestinaux, respiratoires et/ou cutans

Conclusion
Il ne faut pas jouer avec le feu !