Burns

Scalds, flame burns and hot oil burns are unfortunately common hand injuries. Early and appropriate management is very important in achieving an optimal outcome. Hand burns can significantly affect functional capacity and quality of life.

Immediate management: First Aid

The first thing to do when you or someone close to you sustains a burn is to give emergency first aid by holding the burned area under cool (not cold) running water for 20 minutes or until the pain subsides. If it is not possible to hold the affected body part under running water then immerse it in cool water or cool it by applying cold compresses (such as towels or clothing soaked in cool water). Remove any jewellery or burned clothing. Don't apply ice.

After you have cooled the burn cover it with a non-stick dressing. Cling film (plastic wrap) is a good option - it keeps the area clean and can be removed easily so the area can be examined when you reach medical care. Avoid dressing the burn with anything that will allow lint or material to stick to the burn.

Wrapping the area is protective and reduces pain. Burned skin is more painful when it is exposed to the air.

Then seek medical care - from your general practitioner or an Emergency Department.

Will I need surgery?

Most burns will not require surgery, especially if appropriate treatment with dressings and wound care is administered early. The depth of the burn determines its severity. Superficial burns usually heal within 1-3 weeks and do not require surgery, but deep burns may require surgery.

What can I do for the pain?

Keeping your hand elevated above the level of your heart will reduce the swelling that develops after a burn, and will also reduce the throbbing pain. Keeping the burn covered with a dressing also reduces the pain. Be sure to take pain medication at least 30 minutes before each dressing change.

Regular paracetamol and/or ibuprofen are usually safe and appropriate choices for pain medication.

PLEASE NOTE: All medications can have side effects. Please use only as directed. Incorrect use could be harmful. Consult your health care practitioner if pain or symptoms persist.

Do I need to take antibiotics?

Antibiotics are not recommended for burns, although they are prescribed if an infection develops. Watch for signs of infection such as increasing constant pain, redness, fever, swelling and a foul smell. If infection develops seek further medical care.

A tetanus immunisation booster is recommended for burns if you are not up to date.

Dressings for superficial hand burns

Superficial burns do not require surgery and will heal within 1-3 weeks. During this time I recommend that hand burn dressings be directed by a practitioner who has experience in hand burns. The Australian and New Zealand Burn Association criteria for referral to a specialised burns unit includes hand burns; while not all people with hand burns require management in a specialised centre it is certainly best to seek specialist input.

 Dressings are applied to prevent infection, prevent water and heat loss and to promote healing. Fingers with burns need to be dressed individually with the minimal amount of dressing material. This facilitates early movement of the fingers, which helps patients to manage their own self care as well as preventing stiffness of the fingers.

The type of dressing applied varies widely. Some dressings need to be changed daily or every second day. Some dressings only need to be changed weekly. Sometimes the amount of wound ooze determines the frequency of dressing changes. I find that patients prefer (and do best) with dressings that require infrequent changes, are not painful to apply or remove, and are applied in a way that allows the fingers to move as much as possible. Dressings that are impregnated with silver are particularly useful as this has an antibacterial effect.

What should I do with the blisters?

Usually small blisters are best left intact because this is more comfortable and carries less risk of infection. If the blisters are large (greater than a 50 cent piece) or over a joint then your healthcare practitioner may deliberately open the blisters when applying a dressing. Very large blisters will usually burst at the time of burn injury. In this case the loose (dead) skin will usually be removed before your dressing is applied.

Initially the blisters fill with a clear fluid, the same as the fluid that collects in a blister on your foot from ill-fitting shoes. In burns the blister fluid also contains proteins, which can become semi-solid (like egg whites) and make the blister fluid appear 'gluggy'. This is normal and should not be considered a sign of infection.

Hand therapy for burns

Early hand therapy improves outcomes in hand burns. Swelling (oedema) is managed through elevation of the hand, movement and pressure. Reducing swelling minimises stiffness and loss of movement. You may find that wearing a sling helps you to keep your hand elevated; some people find that a sling is uncomfortable and prefer not to wear one. Providing you keep your hand elevated above your heart it does not matter whether you use a sling or not.

Spreading your fingers apart and drawing them together is a good exercise to reduce swelling in burned hands. If you have superficial burns then trying to make a full fist and straighten your fingers is also good. If you have deeper burns then you may be advised to avoid initially making a full fist.

Pressure can be applied to the fingers and hand with special elastic wrap (eg Coban) that can also help keep dressings in place. Patients who have deeper burns may require splinting and other special therapies.

After the dressings finish

Burned skin often heals with pigment changes, so the healed area may be a darker (or lighter) colour than the surrounding skin, especially if the burn was deep or required surgery. The skin remains fragile while it is healing and may remain fragile for many months. During this time you should avoid friction on the skin (because the skin is fragile) and avoid exposing that area of skin to the sun (because sun exposure increases the likelihood that you will have persisting pigment changes). Moisturiser and massage is recommended.

There is a risk of hypertrophic scarring in the burned area. Some of this risk relates to the individual (the patient's age, depth of injury, time taken to heal and personal/genetic predisposition to hypertrophic scarring). Some of the risk can be reduced or modified with appropriate treatment using pressure, silicone, massage, laser and sun avoidance. Click here for information on scar prevention.

Surgery for hand burns

Surgery can be required to debride (clean) burns, especially if the burn is infected. Sometimes skin grafts are required for deep burns, because the amount of damage done to the skin means that there are insufficient skin cells for the wound to heal within 2-3 weeks. Prompt excision and grafting of burn wounds results in less hypertrophic scarring, less contractures and improved outcomes.

Burns to the palmar surface of the hand (fingerprint side; where the skin is thick and sensation is very important) are rarely treated with skin grafts, except in very deep burns. It is more common to require skin grafts to the dorsum (nail side) of the hand.

If you have hand burns it is highly advisable to seek treatment from a specialist who has experience in treating hand burns. This will help to ensure that the assessment and treatment you receive is appropriate for your injury, as this will minimise your recovery time and maximise your eventual outcome. If you have questions please call and make an appointment to see Melbourne Hand Surgery.