Hot-Press Hand Burn Injuries:
Reconstruction and Rehabilitation
C. Scott Hultman, MD; Damon Anagnos, MD
Sydney Thornton, OTR/L; Catherine Calvert, PhD
Bruce Cairns, MD; Michael Peck, MD, ScD
Anthony Meyer, MD, PhD
Divisions of Plastic Surgery & Trauma/Critical Care
North Carolina Jaycee Burn Center
University of North Carolina at Chapel Hill
Introduction
Hot-Press Hand Injuries
• cause of significant hand trauma
• crush/thermal component
• wide range of morbidity
• limited number of case reports
• unknown long-term outcome
Introduction
Hot-Press Hand Injuries
Hot-Press Hand Burn Treatment, Achauer et al,
J Burn Care Rehabil 1998, 19;128-130
• n=17, 1994-1996
• non-op (41%), STSG (47%), flap (12%)
• “normal hand function,” “good” cosmesis
• one complication (minor graft loss)
• no secondary reconstruction performed
Purpose
Hot-Press Hand Injuries
• to assess our experience with hot-press
hand burns
• to determine which factors may influence
functional recovery and return to work
• to provide recommendations for
management
Methods
Hot-Press Hand Injuries
• December 1994 to April 2003
• retrospective analysis
• n=33
• North Carolina Jaycee Burn Center
• multi-disciplinary team of burn and plastic
surgeons, hand therapists,
clinical coordinators, social workers
Methods
Hot-Press Hand Injuries
• burn center database
electronic medical record
chart review
• pre-traumatic history
operative management
post-operative course
long-term outcome
Results
Hot-Press Hand Injuries
• mechanism:
dry-cleaner (26),
industrial press (5), home appliance (2)
• mean age: 37.8 years
• 28 female, 5 male patients
• 17 admissions
• mean length of stay: 11.4 days
• mean follow-up: 17.3 months (range: 1-45)
Hot-Press Hand Injuries
Distribution of Cases by Year
10
8
patient 6
#
4
2
0
1
4
9
9
1
6
9
9
1
8
9
9
2
0
0
0
date of injury
2
2
0
0
Results
Hot-Press Hand Injuries
Acute Management
mean surface area: 122cm2, dorsal >> volar
operative management: 28/33 pts (85%)
damage control: amputation (4), CRPP
fracture (1) fasciotomy/CTR (2)
staged excision: 14/28 pts (50%)
acute coverage: STSG (17), FTSG (4),
groin flap (6), adipofascial turnover flap (1)
Results
Hot-Press Hand Injuries
Adverse Sequelae
18/33 pts (55%)
chronic pain
compressive neuropathy
contracture (dorsal, volar, web)
nail plate grooving
deQuervain’s tenosynovitis
skin graft loss
boutonniere deformity
mallet finger
FDP tendon rupture
12
12
10
4
3
3
2
1
1
Results
Hot-Press Hand Injuries
Post-Traumatic Pain
12/33 pts (36%)
deQuervain’s tenosynovitis
3
carpal tunnel syndrome
cubital tunnel syndrome
compression at Guyon’s canal
chronic pain syndrome
RSD
5
1
2
4
5
Results
Hot-Press Hand Injuries
Secondary Reconstruction 17/33 (52%)
nerve decompression
11
CTR (4), digital (3), Guyon’s canal (2),
cubital tunnel (1), ulnar dorsal sensory (1)
nerve graft
contracture release
tendon reconstruction
1
10
6
tenolysis (3), tendon repair (2), transfer (1)
joint reconstruction
PIP capsulotomy (2), DIP arthrodesis (1)
3
Results
Hot-Press Hand Injuries
Secondary Coverage
adjacent tissue rearrangement
full-thickness skin graft
pedicled flap
3
3
2
reverse dorsal metacarpal perforator flap
reverse posterior interosseous flap
free tissue transfer
serratus
lateral arm
2
Results
Hot-Press Hand Injuries
Neuro-Psychiatric “Continuum”
nerve compression syndrome
reflex sympathetic dystrophy
chronic pain syndrome
seizure disorder
post-traumatic stress disorder
depression and/or anxiety
12
5
4
2
5
33
Results
Hot-Press Hand Injuries
• few patients with normal range of motion
• all patients compliant with occupational
therapy
• return to employment
full-time
restricted/modified
functionally cleared
failure to resume work
malingerers
4 (12%)
5 (15%)
3 (9%)
21 (64%)
none
Summary
Hot-Press Hand Injuries
• devastating injury
• significant long-term morbidity
• early and late complications
• limited functional recovery
• return to work may not occur
Recommendations
Hot-Press Hand Injuries
• early excision +/- staged re-surfacing
• thick sheet grafts vs thin pedicled flaps
• pre-/post-operative hand therapy
• aggressive psycho-social support
• anticipate need for late reconstruction
(nerve decompression, flap revision, contracture
release)