The Journal of hand surgery
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Since opening of the Shriners Burns Institute, Cincinnati Unit, 501 operations for release of burn scar-related contractures of the axilla have been carried out with skin grafting. Six of these cases, 1.2%, resulted in intraoperative stretch injuries to the brachial plexus. In two cases, isolated axillary nerve involvement was encountered. ⋯ Final range of motion, 1 year postoperatively, was normal in all cases. Time to full recovery varied from 2 to 9 months. The importance of preventing the problem by keeping intraoperative motion to a minimum and checking neurologic function promptly in the postoperative period is stressed.
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The posttraumatic syndrome of Volkmann's ischemia and infarction is the end result of compromise of muscle perfusion within the osteofascial compartments of the forearm. The "closed space" arrangement as well as the particular neurovascular anatomy make the flexor forearm muscles particularly susceptible to the cyclic derangement of blood flow, which ultimately results in muscle ischemia and infarction. ⋯ Fasciotomy and epimysiotomy serve to interrupt the cycle. The successful treatment of Volkmann's ischemia requires an understanding of the pathophysiologic mechanisms at work, an appreciation of the subtleties of the clinical presentation, and strong grounding in the details of forearm anatomy and techniques of surgical decompression.
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In summary, although thermal injuries of the upper extremity can produce permanent functional compromise, intelligent management of burns of the hands and fingers can produce fully functional and cosmetically acceptable hands. When the dorsal aspects of the hands alone are injured by thermal insult, the immediate excision of the burned tissue and replacement by split-thickness skin grafts will produce functional and esthetically satisfying results. Should immediate excision and grafting be contraindicated because of massive burns of the body, management by application of topical antibacterial agents and dressings is possible. ⋯ Revisions of hypertrophic and contracted scars can be done at a later date. The stiff and painful hand is not the direct consequence of thermally destroyed skin, but is due instead to the metabolic and biologic complications of unhealed burn wounds. It follows, therefore, that the burn illness should preferably be terminated by prompt excision of the eschar and wound closure by the application of split-thickness skin grafts.