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Functional Restoration Of The Burned Hand: The Role Of Tendon Expansion
Christopher Liao
*1, Roger L. Simpson
21Stony Brook University Hospital, Mineola, NY; 2New York Plastic Surgical Group, Garden City, NY
PURPOSE: Deep burn injury to the hand requires early intervention and rehabilitation to restore function. The kinematics of burn contraction, associated pain, and patient's ability to comply with detailed therapy may create fixed metacarpophalangeal (MP) hyperextension, reducing hand function. Attention to foreshortening of the extensor digitorum communis across the hand is essential to restore digital flexion.
METHODS: Eight hands in six patients (mean age 34 years) with hyperextended MP burn contractures were refractory to further hand therapy. A tissue expander (TE) was placed between metacarpal periosteum and common extensor tendons. After TE filling and removal, MP capsules were released.
RESULTS: Expander fill began at 2 weeks. Two expanders extruded at week 3 (infection) and week 7 (dehiscence). The six remaining hands were brought to completion with a mean filling time of 120 days. Passive flexion at the MP joints was achieved to 90° after release without tension on the extensor tendons. An MP flexion splint was replaced on day three with a dynamic flexion splint. Following recovery of extension, active and passive range of motion exercises overseen by a hand therapist resulted in a mean MP flexion of 69° from a previously fixed hyperextended MP joint at three months. No extension lag was experienced.
CONCLUSION: Deep burns over the dorsal hand require flexion during the acute burn period. Pain is a limiting factor. Burn and/or graft contraction will continue until it meets an opposite opposing force. Maximum flexion at the MP joints early in the post burn/surgery period is essential. MP hyperextension following burn injury creates a concave surface that reduces resistance against graft/burn contraction. Foreshortening of the soft tissue including the extensor tendons will occur when hyperextension is fixed. Longitudinal expansion of the extensor tendons permits rebalancing of MP flexion extension once the capsular contractures are released.
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