Introduction

Burn injuries are common in the pediatric population, representing the fourth leading cause of emergency department visits in the western world. Burns affecting the hand present a significant challenge to the surgeon and therapist. Furthermore, pediatric hand burns require their own unique approach to management and benefit from a multidisciplinary team of surgeons, hand therapists, child life specialists, and other pediatric support staff. These injuries can significantly compromise hand function and growth and therefore necessitate timely and appropriate management to ensure optimal outcomes and quality of life. The challenges of managing hand burns in both children and adults have led to strong recommendations for definitive management at a dedicated burn center whenever possible.

Although burn injuries may result from electricity, chemicals, or radiation, thermal injuries represent most hand burns in children. Most pediatric burns are accidental; however, a high index of suspicion toward nonaccidental injuries should be exercised in this population. In young children, scald injuries tend to be the most frequently observed. Contact burns are another common injury in this age group typically affecting the palmar surface of the hand;

Depending on the type and extent of burn injury to the hand, appropriate surgical and postoperative management is critical to optimize hand function. This chapter will review the pertinent anatomy, classifications, surgical management, and rehabilitation relevant to pediatric hand burns.

Anatomy

The skin comprises epidermis and dermis. The dermis contains important structures of the skin, including the base of hair follicles, sebaceous and sweat glands, capillaries, and nerve endings. The dermis can be further divided into papillary and reticular layers, the latter of which contains many of the aforementioned structures ( Fig. 23.1 ). The palm has hairless, glabrous skin with a relatively thicker dermis. The greatest dermal thickness in the body is found in the volar fingertips.

Jackson’s burn model.

The anatomic differences between the pediatric and adult hands have clinical implications. First, the layers of skin are thinner in children, resulting in greater vulnerability to thermal exposure and making full-thickness injury more likely. Children, however, have more adipose tissue underlying the skin, which protects deeper structures such as tendons, nerves, and vessels. The excess adipose tissue also lends itself to both the excision of eschar and harvesting of full-thickness grafts. Prolonged exposure to the burn source and in friction burns, such as when a child’s hand is in contact with a moving treadmill, can cause extensive injuries to tendons, nerves, and vessels deep to skin and adipose layers.

Another critical difference between adult and pediatric hand burns pertains to the consequences on the growth of the hand. More severe burns and those affecting very young children will have a greater negative impact on the growth of the hand. This is related to the potential for scar contractures of skin and joints that restrict growth.

Classification

This classification of burns is based on the depth of skin exposure ( Table 23.1 ).

Specific classifications of hand-related burns in children have also been proposed to guide therapy. Burns causing flexion contractures at the proximal interphalangeal (PIP) joints of the fingers and the thumb may be classified according to Stern et al. ( Table 23.2 ). Moreover, burns causing hyperextension contractures of the metacarpophalangeal (MCP) joints may be classified according to Graham et al. ( Table 23.3 ).

Approach to Treatment

Robson et al. outlines core principles for improving outcomes in hand burn injuries. These principles include prevention of burn propagation to deeper structures, prompt wound closure/grafting, preservation of range of motion both at the level of the hand and the remainder of the extremity, prevention and control of infection (to mitigate extension of nonviable tissue), and early retraining. Robson advocates for a multidisciplinary team consisting of physician, nurse, occupational therapist, physical therapist, vocational rehabilitation counselor, and social worker.

Clinically significant burns should be initially managed according to the advanced burn life support and advanced trauma life support when associated with concomitant trauma protocols. Specific management of pediatric hand burns should be implemented once the patient is medically stable.

Preoperative Evaluation

A focused history should be obtained including timing, type, and duration of burn injury as well as other concomitant injuries to the hand(s). Nonaccidental injuries, either neglect or abuse, should be promptly identified and reported to the appropriate child protection services. Incidence of nonaccidental burns has reportedly been as high as 25%. In addition to the history of presenting injury, certain burn patterns identified during examination may lead to a higher likelihood of neglect or abuse. Burns to certain anatomic sites should raise the suspicion of abuse, such as burns to perineum, ankles, plantar aspect of the feet, wrists, and palmar aspect of the hand. Burns with a clean line of demarcation in a glove and/or stocking pattern, or symmetric burns should raise the suspicion for nonaccidental injury.

The burn depth can be assessed using the aforementioned classification system ( Table 23.1 ). Extent can be determined based on percentage of total body surface area (TBSA) using a Lund and Browder Chart ( Fig. 23.2 ); however, a detailed description of dorsal and palmar involvement of digits and joints should be documented. Careful assessment is essential to rule out any circumferential burns or other signs of vascular compromise that will require immediate intervention. Appropriate physical examination may require initial debridement that is usually performed under conscious sedation in the emergency department, burn treatment room or the operating room.

Lund and Browder Chart.