Five Essential Principles for First Web Space Reconstruction in the Burned Hand

Abstract

Background: Burn injuries commonly affect the hand, and the development of adduction contractures of the first web space is frequent and deleterious, both functionally and aesthetically. Many corrective techniques and algorithmic approaches have been described to treat this problem, but there is no consensus on the optimal management. Methods: A retrospective review at a single high-volume pediatric burn center was undertaken to evaluate the clinical course of these patients. All pediatric patients undergoing initial release of burn scar contracture of the first web space from 2005 through 2015 were included in a retrospective cohort study. Results: The authors identified 40 patients with 57 burned hands. The initial approach to management was variable. Z-plasty or other local flap was the first technique used in 28 hands (49 percent), split-thickness skin graft in 19 hands (33 percent), full-thickness skin graft in seven hands (12 percent), groin flaps in two hands (4 percent), and a reverse radial forearm flap in one hand (2 percent). The mean numbers of total reconstructive procedures per hand including the initial procedure were as follows: groin flap, 4.0; full-thickness skin graft, 3.1; split-thickness skin graft, 2.1; Z-plasty, 1.4; and reverse radial forearm flap, 1.0. Conclusions: Successful reconstruction of the first web space must be addressed in the context of the entire hand. It is the authors’ preference to use split-thickness skin grafting whenever a skin deficiency is present—only then should leading edge contractures be addressed with Z-plasty. Based on their experience, the authors recommend five principles that are essential to successfully treat postburn contractures of the first web space. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Reply: Five Essential Principles for First Web Space Reconstruction in the Burned Hand

“…It has a high correlation with the surgical findings, signifying advantages over hand-held Doppler and computed tomographic angiography in sensitivity, specificity, and accuracy. 1 Although the Doppler examination has proven to be less accurate in locating perforators compared with color duplex ultrasonography and computed tomographic angiography, 2 it will probably remain…”

“…I thank Drs. T. Yamamoto and N. Yamamoto for their letter regarding the article “Five Essential Principles for First Web Space Reconstruction in the Burned Hand.” 1 They appropriately draw attention to the superficial circumflex iliac artery pure skin perforator–based superthin flap from the groin described by Narushima et al in 2016. 2 This elegant flap is a creative way to provide thin, elastic, vascularized flap coverage when complex deep tissue injuries accompany hand burns.…”

Correction of hand deformities after burns

“…Adduction contracture of the first web space is an adduction contracture of the thumb due to fibrosis of the adductor muscle or first dorsal interosseous and is distinct from the aforementioned web space contracture [17]. Web space contracture is confined to the skin, whereas adduction contracture is accompanied by muscle fibrosis.…”

Deep Peroneal Nerve: From an Anatomical Basis to Clinical Implementation

“…The first web space contracture in a burned hand is one of the most common problems resulting in significantly decreased hand function. To achieve the goals following specific treatment principles 71,72 , there are many options possible for the surgical reconstruction, including skin grafting 73,74 , local flaps 75,76 , regional flaps 77 , and free flaps. 78,79,80 According to the principles, healthy tissue replacement or rearrangement is not sufficient.…”