Management of hand burns using

tangential excision and grafting

versus delayed excision and grafting
International Surgery Journal. 2019 Jun;6(6):2097-2103

Dev J. Sharma*, Vijay Langer

Department of Plastic Surgery, Command Hospital, Western Command,
Chandimandir, Haryana, India

Presented by:
Rizka Khairiza
at
Journal Reading Club PERAPI Joglosemar

25/8/2020
 An open access, peer-
reviewed surgery journal.
Indexed internationally.

Consisted of 14 word.
Key trial objectives
are stated. Describe
the entire contents of
the journal well.

Authors, institution and

correspondence are
completely adressed.

Sharma DJ, Langer V. Management of hand burns using tangential excision and grafting versus delayed excision and grafting. Int
Surg J. 2019;6(6):2097. Available from: https://www.ijsurgery.com/index.php/isj/article/view/4270
 Problem and research question
are well described.

The study design are not clearly stated.

Sample and research procedure briefly
explained. Outcome and measuring tools
are not evidently mentioned.

Outlines the research findings.

Does not statistically represent key
objectives.

Clearly answer the question of interest

Represent topic of study

(except word of thermal burns [?])
Critical Appraisal
Using critical appraisal tool worksheet
from Oxford Centre for Evidence-Based
Medicine (CEBM)

Available at:
https://www.cebm.net/2014/06/critical-appraisal/
P Hand burn patients in the Burn Centre of Command Hospital of Indian Army.

I Tangential excision and grafting

C Early vs. delayed excision (each followed by grafting)

Function, aesthetic, satisfaction, pain, activity of daily living (ADL),

O secondary procedure
√
But the author(s) does not provide the exact explanation about
the implementation of random allocation.
 Observed Group I Group II
Age 30.7 34.3
TBSA burnt 33.09% 38.33%
TBSA excised 11.07% 13.57%
Flame burns 33/42 30/2
Scald burns 5/11 6/11
Electric burns 2/4 2/4
Flash burns 2/4 2/4
Chemical - 2/2

√
√
None
√ √
Briefly explained about the use of splinting and pressure garment
√
None
 √
The application of blinding to person in charge for data processing/statistician is not
mentioned either
•v

Comment: The author(s) use OR instead of RR

Comment: None
Comment:

• Validity:
The (internal) validity of this study has not yet
explained scientifically.
• Importance:
This study provides substantial and important
knowledge regarding surgical therapy of burn
wound.
• Applicabillity:
It may require more/higher research before it
can be applied as evidence-based medicine
Journal Review
Background and Research Question
• Hands are frequently affected by serious and deep
burns, more often located on the dorsum

• Hands: small TBSA, big functional and social role

• How to prevent the horrific scarring associated with

burns and to preserve function?

• This study aimed to compare and study the

management of hand burns using early tangential
excision and grafting, and delayed excision and
grafting in terms of:
1. Functional outcome
2. Aesthetic outcome,
Pic courtesy: Adobe Photo Stock
3. Requirement of a secondary procedure
Methods
• Design of study : Study of therapy / Quasi Eksperimental

• Group :
✓ Early tangential excision + grafting (Group I) → Intervention/test group
✓ Delayed excision + grafting (Group II)

• Measured Outcome:
1. Aesthetics
2. Satisfaction
3. Pain
4. Activity of daily living (ADL)
5. Requirement of a secondary reconstructive procedure
6. Function
Study Area and Targeted Population

• Burn patients involving hand(s) who is

referred/transferred from peripheral
hospitals or directly admitted to the Burn
Centre of Command Hospital, Western
Command, of Indian Army

• Between Jan 2015 to Dec 2016

Pic courtesy: The West Bengal University of Science

Sample Criteria
Inclusion
• patients with indeterminate, deep-partial or full
thickness burns of hand below 70% TBSA
• admitted to the Burns Centre between Jan
2015 to Dec 2016
Exclusion
• Patients with ‘indeterminate’ hand burns who
healed completely by the end of three weeks
• Patients with poor general condition or with
poor initial resuscitation when referred from
peripheral hospitals
• Patients with burns of more than 70% TBSA
• Patients who were lost to follow up or where
follow up period was less than six months
 Sample Size and
Research Flow

“
Data Collection Technique and Tool
1. Aesthetics, satisfaction, pain, activity of daily living and
requirement of a secondary reconstructive procedure

• Measured using score 1-10 taken from the patient and treating
surgeon (first author)
• Aethetics, satisfaction, ADL:
5 ≤ = poor / ≥ 6 = good
• Pain, secondary procedure:
5 ≤ = good / ≥ 6 = poor
• Measured at the end of 12th months of follow up

Well settled aesthetically pleasing skin graft (upper)

and good fist formation (lower) in Group II patient.
 Cont’d

2. Functional assessment → pinch and palmar grip strength

- Assessed using portable hydraulic hand dynamometer
- Compared to normal values of 100 healthy subjects
(7 kg for pinch strength; 42 kg for palmar grip strength)
- Measured using score 1-10 at the end of 1st month
≥ 90% = 10; 80-89% = 8, 70-79% = 7, and so on.
- Pediatric age groups were not measured

*splinting and pressure garment were used as standard

procedure

Pinch (upper) and power grip (lower) measurement

Results
• Total of 104 patients with deep-partial thickness or full thickness burns of hands
→ 31.2% of all admissions
→ ♂ : ♀= 1,63 : 1

• 84 patients (140 hands) involved in this study:

✓ 56 patients (80% of hands) had bilateral hand burns
✓ 28 patients (20% of hands) unilateral hand burns
Results
Average Value
Observed #AGE
Group I Group II
Ranged from 10 months to 75 yrs.
Age 30.7 34.3 • 39 patients (46.4%) were 21-40 yrs
TBSA burnt 33.09% 38.33% • 17 Patients (20%) below 15 yrs
• 5 patients (5.9%) above 61 yrs
TBSA excised 11.07% 13.57%
Flame burns 33/42 30/2
Scald burns 5/11 6/11
Electric burns 2/4 2/4
Flash burns 2/4 2/4 # WOUND AREA
Chemical - 2/2
Varies from 7% to 60%.
Graft take 88.28% 82.11% • 31/84 patients (36.9%) had 21-40%
burnt TBSA
Blood requirement 2.80 units 1.49 units • 19/31 patients (22.6%) → Group I
• 12 patients (14.3%) → Group II
LOS 23.2 days 53.2 days
 Cont’d
Flash burns
Chemical burns

Electric burns
# ETIOLOGY
Work related accidents and domestic
accidents.

Schalds
✓ 63/84 patients (75%) → flame burns
✓ 11/84 patients (13,1%) → scalds
✓ 4/84 patients (4.8%) → electric burns
✓ 4/84 patients (4.8%) → flash burns
✓ 2/84 patients (2.4%) → chemical burns
Flame Burns
• Children
✓ 10/17 → scalds
✓ 7/17 → flame burns
Cont’d

*reverse score in pain and secondary procedure

 Cont’d

• “ The odds of getting the outcome as good aesthetic outcome was

more than five times in Group I rather than Group II, with a
statistically significant p value (0.04).
• For secondary procedures, the odds of receiving a good score in
Group I compared to that in Group II was 3.15 times. This value was
statistically significant (p=0.008).
Cont’d

1. Aesthetic → significant 5. ADL → undefined

(unfastening of shirt buttons, unlocking the locks, tying shoelaces,
2. Functional → not significant ability to write legibly and to sign documents, combing of hair,
3. Satisfaction → not significant self feeding).

(for overall treatment and result, included social acceptance at 6. Secondary procedure → strongly significant
work place and home)

4. Pain → not significant.

“Group I is superior to group II in all assessment parameters except pain.”
Cont’d
Observed deformities:

✓ Hypertrophic scarring
✓ Dorsal skin contractures
✓ Web contractures ✓ Fifth finger abduction
✓ Linear scar bands deformity
✓ Sponge deformities ✓ Extensor tendon
adhesions
✓ Boutonnière deformities

Group I Group II
Discussion
• There are two surgical approaches for patients with deep partial-thickness and full thickness burns
to the hand :
✓ An early tangential excision and skin grafting → within the first few days of injury
✓ an initial topical treatment followed by late eschar excision and grafting.

• Both techniques have advantages and limitations

*Supplementary
What is tangential excision?
“Excision of the necrotic surface of a burn, taking repeated slices parallel to the skin surface using a skin graft knife;
this is in contrast to cutting down to fat or deep fascia with a scalpel and excising burned skin and subcutaneous tissue together.
The procedure consists of tangential excision and grafting. It is a diagnostic procedure as well as a surgical preparation of a
recipient bed for skin grafts, to achieve early closure of a particular type of burn wound.”

Janzekovic Z. A new concept in the early excision and immediate grafting of burns. J Trauma. 1970 Dec;10(12):1103–1108.
Jackson DM, Stone PA. Tangential Excision and Grafting of Burns: The Method, and a Report of 50 Consecutive Cases. Br J Plast Surg. 1972; 25:416-426
Early Tangential Excision and Grafting
• Suitable in partial-thickness and full
thickness burns; considering individual
general condition and severity of burn
wound

• If more extensive and potentially life-

threatening burns are present, excision and
closure of the large surface always take
priority over hands

• If only hands are burned, surgery should be

done at the earliest opportunity
→ The occurance of late complications are Tangential excision of burn wound of the finger

low and relatively easier to treat.

Cont’d
• Suggested to be done within two weeks

• Pros:
Janzekovic Z. A new concept in the LOS,
✓ Shorter early excision and hospital admission
less costly
immediate grafting of burns. J Trauma. 1970 Dec;10(12):1103–
1108. [PubMed] [Google✓Scholar]
frequency of late complications and need for secondary
reconstructive surgery is no different

• Complications may arise: web contractures, linear scar bands,

sponge deformity at graft edges

Tangential excision of burn wound (upper);

covered with meshed autograft (lower)
Cont’d
• Cartoto (2005):
→ 29 patients managed with early excision and grafting. A year/more after injury, patients had
normal mean pinch strength but decreased grip strength. Mean TAM of 225 degrees, which is
considered functional

• Ong et al (2006):
→ Early excision of burns is beneficial in reducing mortality (in patients without inhalational
injury), and length of hospital stay. The drawback is the greater volume of blood loss”

Cartotto R. The Burned Hand: Optimizing Longterm Outcomes with a Standardized Approach to Acute and Subacute Care. Clin Plast
Surg. 2005;32:515-27.
Ong YS, Samuel M, Song C. Meta-analysis of early excision of burns. Burns. 2006;32(5);145-50.
Delayed Excision and Grafting
• Advocated to preserve all viable tissue till eschar separates out on its own by the end of three
weeks.

• If eschar is still adherent by the end of three weeks → surgically excised, raw areas are skin grafted

• Some surgeons consider preservation of all residual, viable dermal elements as critical importance
and opt for late surgery following eschar separation, when necessary

• Pros:
✓ functional results are as good as those with early surgical approach
✓ frequency of late complications and need for secondary reconstructive surgery is no different
Limitation
• Small sample size, thus cannot be said to be conclusive for general population

• Randomization of subjects into two groups was done keeping in mind the age profile, mode of
injury, extent of burns and the time of reporting to our burn centre

• Early surgical approach was not always possible, regarding individual general condition and
severity of burn wound, thus influence the randomization

• The follow up period ranged from 6 to 24 (with a mean of 1 year) which may have influenced
certain scores awarded by the patients.
Conclussion
1. The skin graft take was much superior in early excision group as compared to delayed group and
hence resulted in decreased overall hospital stay

2. The functional and aesthetic outcomes were better achieved and the needs for secondary surgical
revision were far lesser with early excision and grafting.

3. Both early excision and grafting and delayed excision and grafting lead to post burn deformities
of hand, but more common with delayed grafting.

4. the requirement of blood and blood product to be significantly higher in early tangential and
grafting