Acute deep hand burns covered by a pocket flap-graft: long-term outcome based on nine cases

Abstract

Objective: We evaluated the long-term outcome of the "pocket flap-graft" technique, used to cover acute deep burns of the dorsum of the hand, and analyzed surgical alternatives.

Methods: This was a 6-year, retrospective study of 8 patients with extensive burns and 1 patient with a single burn (11 hands in all) treated by defatted abdominal wall pockets. We studied the medical records of the patients, and conducted a follow-up examination.

Results: All hands had fourth-degree thermal burns caused by flames, with exposure of tendons, bones, and joints, and poor functional prognosis. One third of patients had multiple injuries. Burns affected an average of 36% of the hand surface, and mean coverage was 92.8 cm(2). One patient died. The 8 others were seen at 30-month follow-up: the skin quality of the flap was found to be good in 55% of the cases, the score on the Vancouver Scar Scale was 2.4, the Kapandji score was 4.5, and total active motion was 37% of that of a normal hand. Hand function was limited in only 2 cases, 8 patients were able to drive, and 3 patients had gone back to work.

Conclusion: The pocket flap-graft allows preservation of hand function following severe burns, when local or free flaps are impossible to perform. Debulking of the flap at the time of elevation limits the need for secondary procedures.

Figure 1

Surgical technique. (a) After excision of necrotic tissue and splinting of the extended fingers with Kirschner wire, the hand was placed in the subcutaneous pocket. (b) The hand was immobilized, and the fingers were separated with an external fixation. (c) After 3 weeks, the hand was cut free from the abdominal wall. The donor site was covered with an autograft. (d) The interdigital webs were separated at the same time, or 2 weeks later, and the Kirschner wires were withdrawn 10 days later.

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.

Figure 3

Clinical case 2. (a) Deep burn to whole hand requiring multidigit amputations, appearance after debridement. (b) Defatted pocket-flap on abdomen. The zone utilized for the flap also served at the same time as donor site for thin skin autograft. (c) Appearance after separation of fingers. (d) Appearance of donor site. (e and f) Comparative functional results.

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 5

Clinical case 9. (a) Deep burn of the palmar side of the hand. (b) Deep burn of the dorsal side of the hand on day +34 after a failure of Integra. Appearance after excision of necrotic tissue and splinting of the extended fingers with Kirschner wire. (c) The picture shows the hand cut free from the abdominal wall after 7 weeks immobilized in a subcutaneous pocket of the thigh. (d) Appearance after separation of fingers. (e) Appearance of hand at 5 months, without alteration (extension on palmar side). (f) Appearance of hand at 5 months (flexion on radial side).