Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 12  |  Issue : 1  |  Page : 17-20

Early experience with tangential excision and skin grafting of deep dermal burns of the hand among diabetics and nondiabetics


1 Department of Plastic, Reconstructive Surgery and Burns, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
2 Department of Surgery, Jawahar Lal Nehru Memorial Hospital, Ministry of Health, Srinagar, Jammu and Kashmir, India
3 Department of Plastic, Reconstructive Surgery and Burns, King Fahad General Hospital, Jeddah, Saudi Arabia

Date of Web Publication10-Nov-2016

Correspondence Address:
Mir Yasir
H. No. W-13, Shah Faisal Colony, Upper Soura, Srinagar, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0794-9316.193735

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  Abstract 

Introduction: Deep dermal injury of the hand should have a special management because it has a high potential to affect the functional capabilities of the hand. This study was established to measure the outcome of managing these special types of patients and comparing their outcome with nondiabetics. The goal was to intervene and cover the wound within a time limit of <14 days.
Patients and Methods: Between the period of November 2011 and October 2013, we managed a total number of 12 patients with deep dermal burn to the hands in the Burn Unit at King Fahad General Hospital, Jeddah . Four patients were insulin-dependent diabetics, and eight were nondiabetics. An early tangential excision and skin grafting was done in these patients within 14 days of injury.
Results: All 12 patients were male. The average age was 45 years. The average total body surface area (TBSA) burnt was 35%, with a range of 2-65%. Four patients were insulin-dependent diabetics, whereas eight patients had no medical comorbidity. Two of the diabetics had an isolated hand burn, and the other two had 30% and 50% of TBSA full-thickness burn, respectively. The graft take was satisfactory among the patients with no difference between the diabetics and the nondiabetics. The grafted hands underwent physiotherapy following the procedure. Satisfactory outcomes were seen among all the grafted hands, with near return to full function.
Conclusions: Tangential excision is recommended during the first 5 days postburn to reduce the risk of infection and graft loss. Diabetic patients do not behave differently from nondiabetic patients in their response to graft take, wound healing, and return to work.

Keywords: Dermal burns, diabetic hand, tangential excision


How to cite this article:
Bijli AH, Yasir M, Khan TS, Al Daheri H, Banoqitah MM, Bagdadi A. Early experience with tangential excision and skin grafting of deep dermal burns of the hand among diabetics and nondiabetics. Nigerian J Plast Surg 2016;12:17-20

How to cite this URL:
Bijli AH, Yasir M, Khan TS, Al Daheri H, Banoqitah MM, Bagdadi A. Early experience with tangential excision and skin grafting of deep dermal burns of the hand among diabetics and nondiabetics. Nigerian J Plast Surg [serial online] 2016 [cited 2019 Aug 19];12:17-20. Available from: http://www.njps.org/text.asp?2016/12/1/17/193735


  Introduction Top


The prevalence of diabetes mellitus among Saudi Arabian population is high. [1],[2] Among the burn-related morbidities, thermal injury of the hand is one of the most demanding entities for the burn surgeon to treat. [3] A good number of patients with hand burns are diabetics. Studies regarding the prevalence of diabetes in Middle Eastern countries have shown that 23.7% of adult Saudis in the age of 30-70 years have diabetes, and 14.1% have impaired fasting glucose. [2] There is a fear of impaired wound healing in diabetics with vascular, neuropathic, immunological and biochemical abnormalities, as each contribute to altered tissue repair. [4],[5],[6],[7] It remains a challenge to the treating surgeon to achieve full hand function and an early return to work for these patients. Early tangential excision is an established practice now in burn management, but the application of the same in diabetic population with hand burns needs extra care. [8],[9],[10] A precise estimate of burn depth is essential for planning the most appropriate management of the burned hand. [11] Superficial burns which heal within 2 weeks are nearly always treated conservatively while deep dermal and full-thickness burns require surgical intervention at the most appropriate time. Strict blood sugar control from the start of admission is essential for better outcome in these patients. The purpose of this study is to emphasize that the treatment of deep dermal and full-thickness burns of the dorsum of the hand is essentially not different in diabetics and nondiabetics, provided that relevant care for blood sugar control and more early excision and skin grafting is performed for diabetic patients with hand burn.


  Patients and methods Top


From November 2011 to October 2013, we managed a total number of 12 patients with deep dermal burn to the hands in the Burn Unit at King Fahad General Hospital, Jeddah. All patients were admitted within 24 h of injury, and each received their initial resuscitation according to the Parkland formula, with insulin sliding scale started for the diabetics. The burns were initially cleaned with mild detergent soap and debrided. Silver sulfadiazine was applied. All hands were elevated. Escharotomy was done as indicated. All 12 patients were managed with a classical tangential excision and skin grafting [Figure 1],[Figure 2],[Figure 3] and [Figure 4]. Eight hours before surgery, povidone-iodine ointment was applied to the burn surface in all, except two patients. This agent has two-fold purposes: (1) Drying and hardening the eschar making the excision easier and (2) the application of this agent imparts a transparent appearance to the eschar. Thrombosed dermal blood vessels are more easily identified making it easier to differentiate between deep dermal and third-degree portions of the wound. [11] Two patients had silver sulfadiazine dressing; this caused the eschar to be soft and difficult to excise, resulting in longer operative time. Tangential excision was always performed under general anesthesia, using a tourniquet with total circulatory occlusion of the extremity. The arm and hand are not elevated before inflating the tourniquet so that blood will be trapped in patent dermal vessels. Identification of the proper level of tangential excision is ascertained when a vascular "ooze" or a "white moist surface in the dermis" is identified. Repetitive slices of necrotic burned tissue were carefully removed from the dorsum of the hand using an adult electrical dermatome, whereas pediatrics electrical dermatome was used to excise eschar over the fingers until viable tissue surface was reached, and vigorous bleeding points were seen, which when swabbed revealed a glistening, white bed, denoting viability and readiness to accept the graft. Before the tourniquet was released, the hand was wrapped with adrenaline-saline-soaked sponge dressing, and pressure was applied for at least 10 min to stop the bleeding. In the meanwhile, the skin graft was harvested. The temporary pressure dressing was released, recipient area was irrigated free of clots, and complete hemostasis was ensured before the graft was applied. One patient bled heavily, with little benefit from the adrenaline-saline-soaked sponge dressing; therefore, the graft was put immediately after removing the dressing which controlled the bleeding. The graft was fixed to the dorsum with staples. The hand was dressed in a functional position with paraffin gauze, and a voluminous dressing was applied. The dressing was removed on the third postoperative day, and the graft was inspected for take. Physiotherapy and functional exercises were initiated only 3-5 days after the initial postoperative dressing.
Figure 1: Diabetic patient with deep burn hand

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Figure 2: Early tangential excision done with grafting

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Figure 3: Follow-up picture showing well-settled skin graft

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Figure 4: Good range of motion

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  Results Top


All 12 patients were male. The average age was 45 years. The average total body surface area (TBSA) burnt was 35%, with a range of 2-65%. Four patients were insulin-dependent diabetics, whereas eight patients had no medical comorbidity. Two of the diabetics had an isolated hand burn, and the other two had 30% and 50% of TBSA full-thickness burn, respectively.

After 3 days of the procedures, the dressing was removed and the grafts were inspected. The graft taken was complete in all the cases, except one diabetic patient who had a central 3 cm × 3 cm patch of graft loss which subsequently healed by secondary intention. Dressing every other day was done with fusidic acid cream and antiseptic dressing. The hand function in all patients was satisfactory, and all went back to work. Patient's follow-up ranged from 1 month to 1½ years. On discharge from the hospital, all patients were followed biweekly in the physical therapy department and weekly in the outpatient clinic and eventually at 3 months interval, ensuring continued proper physical therapy and evaluation of both hand function and cosmetic appearance. Range of motion has remained excellent [Figure 3] and [Figure 4], and many of the patients who were actively employed before the surgery had returned to some types of work status.


  Discussion Top


Prevalence of diabetes in Saudi Arabia has been reported as 34.1% in males and 27.6% in females. [1] The mean age of patients was 55.3 years. Other studies report the prevalence of 23.7% of diabetes in adult Saudis and 14% with impaired fasting glucose. [2] Among these, hand burns should take a special consideration due to its potential of affecting the patient's functionality. The ultimate goal in treating any thermally injured patient is early closure of the burn wound. Spontaneous reepithelialization of a deep dermal burn is equivalent to delayed closure of the wound. [12] It is not unusual for this type of wound to take 3-5 weeks to heal. Certain anatomical areas of the body, such as the back and buttocks, are of low priority for excision because of their posterior location and generous thickness of the dermis and therefore, lend themselves to conservative therapy. [3] It is inadvisable for a number of reasons to treat deep dermal burns of the dorsum of the hands and fingers conservatively. [11] Tangential excision is ideally recommended during the first 5 days postburn to reduce the risk of infection and graft loss with improved survival. [8],[9],[10],[13]

Early wound closure of the burned hand has its greatest asset in accomplishing early mobilization. An open wound is painful and immobilization lessens wound pain. In many anatomic areas of the body, this is of no consequence, but this has disastrous consequences in the upper extremity. As long as the wound remains open, tissue edema persists. The combination of tissue edema and immobilization in the hand and digits, particularly of the interphalangeal joints, promotes small joint stiffness. [14] In all patient populations, prevention of proximal interphalangeal joint stiffness of the hands is of paramount importance. Nonoperative management of deep dorsal hand burns requires both continuous splinting and elevation of the extremity for a prolonged period. This imposes additional nursing and physical therapy management which can be eliminated by early surgical excision and autografting. [3]

Diabetic patients are known to experience more infections in clean wounds than nondiabetic patients and to heal more slowly, especially in extremities. [4],[5] Although topical antimicrobial agents are used to control the bacterial population of the burn wound, infection still continues to be a threat to patient survival. In small burns, systemic sepsis is unusual, but local wound sepsis can cause conversion of the second-degree burn to a deeper depth or even a full-thickness injury. Early closure of the burn wound prevents this complication. [15] Early closure of dorsal hand and finger burns has a significant nutritional and psychological impact on the patient's recovery. [3] Early utilization of the hands for feeding purposes is, without doubt, a great advantage, and the patient becomes less dependent on hospital personnel and more dependent upon himself. The timing of burn wound excision is of utmost importance, especially in diabetics. More the delay, more likely is the chance of developing wound infection before surgery and eventually a higher risk of graft loss in this subset of population. In our series, we observed partial graft loss in only one patient (8.3%). Delaying the surgery can lead to increase in bleeding tendency intraoperatively. It was found in our series that the graft is the best hemostat. Direct application of the graft over a heavily bleeding area, posttangential excision assisted in stopping the bleeding. Tangential excision should always be carried out under a tourniquet. Reluctance to use this technique, for fear of the difficulty of judging the depth of excision, is not a valid argument since one can always see the punctate bleeding spots when viable tissue has been reached. At the same time, the color of the wound base is clearly visible, providing further evidence when the excision has reached the desired depth. [11]

Physiotherapy and functional exercises were initiated 3-5 days after the first postoperative dressing. It has been seen that early physical therapy of the burned hands postoperatively decreases the long-term morbidity and helps in achieving the favorable outcome. [16] Similar observations were noted in our series where patients returned to some types of work postoperatively.


  Summary and conclusions Top


Tangential excision is ideally recommended during the first 5 days postburn to reduce the risk of infection and graft loss. Most of the patients were operated in the 1 st week, and no difference was noticed as regards the incidence of infection and the final results between diabetics and nondiabetics. We conclude that diabetic patients do not behave differently from nondiabetic patients in their response to graft take, wound healing, and return to work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Alqurashi KA, Aljabri KS, Bokhari SA. Prevalence of diabetes mellitus in a Saudi community. Ann Saudi Med 2011;31:19-23.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Al-Nozha MM, Al-Maatouq MA, Al-Mazrou YY, Al-Harthi SS, Arafah MR, Khalil MZ, et al. Diabetes mellitus in Saudi Arabia. Saudi Med J 2004;25:1603-10.  Back to cited text no. 2
    
3.
Hunt JL, Sato R, Baxter CR. Early tangential excision and immediate mesh autografting of deep dermal hand burns. Ann Surg 1979;189:147-51.  Back to cited text no. 3
    
4.
Goodson WH 3 rd , Hunt TK. Wound healing and the diabetic patient. Surg Gynecol Obstet 1979;149:600-8.  Back to cited text no. 4
    
5.
Morain WD, Colen LB. Wound healing in diabetes mellitus. Clin Plast Surg 1990;17:493-501.  Back to cited text no. 5
    
6.
Alexander JW. Mechanism of immunologic suppression in burn injury. J Trauma 1990;30 12 Suppl: S70-5.  Back to cited text no. 6
    
7.
Memmel H, Kowal-Vern A, Latenser BA. Infections in diabetic burn patients. Diabetes Care 2004;27:229-33.  Back to cited text no. 7
    
8.
Engrav LH, Heimbach DM, Reus JL, Harnar TJ, Marvin JA. Early excision and grafting vs. nonoperative treatment of burns of indeterminant depth: A randomized prospective study. J Trauma 1983;23:1001-4.  Back to cited text no. 8
    
9.
Gray DT, Pine RW, Harnar TJ, Marvin JA, Engrav LH, Heimbach DM. Early surgical excision versus conventional therapy in patients with 20 to 40 percent burns. A comparative study. Am J Surg 1982;144:76-80.  Back to cited text no. 9
    
10.
Hart DW, Wolf SE, Chinkes DL, Beauford RB, Mlcak RP, Heggers JP, et al. Effects of early excision and aggressive enteral feeding on hypermetabolism, catabolism, and sepsis after severe burn. J Trauma 2003;54:755-61.  Back to cited text no. 10
    
11.
Fadaak HA. Experience with early tangential excision in the management of deep dermal burns on the dorsum of the hand. Ann Burns Fire Disasters 2001;16:25.  Back to cited text no. 11
    
12.
Atiyeh BS, Ghanimeh G, Nasser AA, Moucharafiel RS. Surgical management of the burned hand: An update and review of literature. Ann Burns Fire Disasters 2000;13:230-3.  Back to cited text no. 12
    
13.
Thompson P, Herndon DN, Abston S, Rutan T. Effect of early excision on patients with major thermal injury. J Trauma 1987;27:205-7.  Back to cited text no. 13
    
14.
Peacock EE Jr., Madden JW, Trier WC. Some studies on the treatment of burned hands. Ann Surg 1970;171:903-14.  Back to cited text no. 14
    
15.
Levine BA, Sirinek KR, Peterson HD, Pruitt BA Jr. Efficacy of tangential excision and immediate autografting of deep second-degree burns of the hand. J Trauma 1979;19:670-3.  Back to cited text no. 15
    
16.
Mahler D, Benmeir P, Ben Yakar Y, Greber B, Sagi A, Hauben D, et al. Treatment of the burned hand: Early surgical treatment (1975-85) vs. conservative treatment (1964-74). A comparative study. Burns Incl Therm Inj 1987;13:45-8.  Back to cited text no. 16
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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