Thermal, Chemical, and
Electrical Burns

Ziv M. Peled and Jonathan S. Schreiber

History and Clinical Presentation

A 77-year-old man undergoing chemotherapy for lung cancer was seen in consultation by the plastic surgery service after suffering a burn injury to the dorsum of his right hand. A previous intravenous (IV) site had infiltrated in the man’s right hand and this was removed. A different site was begun in another location for administration of mitomycin C. The chemotherapeutic agent extravasated at the site of the first IV line in the right hand, resulting in a chemical burn.

PEARLS

• There are multiple ways to treat burns of the hand, depending on the degree of the burn and associated injuries. Several principles should always be kept in mind and are critical to a successful outcome. These are early debridement and edema/infection control, early wound coverage, and early mobilization. Adherence to these simple principles will likely prevent or minimize common postburn complications such as flexion contractures and boutonniere deformities.
  
• When completing the dissection of a distally based flap, the surgeon should examine the flap for evidence of venous congestion. If venous congestion is noted, a venous anastomosis should be performed to achieve adequate flap drainage. This technique, although infrequently necessary, can improve flap viability.

PITFALLS

• Evaluation of a burn wound is challenging because the thickness of burn is often difficult to determine initially.

Physical Examination

On initial examination the involved skin and subcutaneous tissue were cellulitic with a small area of necrosis. Initial debridement was performed in the office and revealed that the wound extended to the level of the deep subcutaneous tissue. The extensor tendons were noted to be covered by soft tissue and paratenon. Normal saline dressings were used to promote granulation tissue for possible future split-thickness skin grafting. Despite meticulous wound care, the overlying soft tissue became necrotic and required further debridement with resultant broad exposure of the extensor communis tendons. Minimal granulation tissue formation was noted. The patient was subsequently admitted to the local university hospital for workup and definitive treatment.

Differential Diagnosis

Thermal burns

Chemical burns

Electrical burns

Diagnosis

Chemical Burn

The patient had a chemical burn caused by extravasation of mitomycin C. Tissue necrosis and sloughing is known to occur with extravasation of several types of chemotherapeutic agents and is well described with the use of mitomycin C. This tissue reaction has been known to occur at sites distant from the injection site.

Alternative Methods of Management

The primary goal in the treatment of all hand injuries is to restore optimal function. There are multiple ways to treat burns of the hand, depending on the thickness and extent of the burn and associated injuries. Several principles should always be kept in mind. Early debridement, edema/infection control, early wound coverage, and early mobilization are critical to a successful outcome. Adherence to these simple principles will likely prevent or minimize the most difficult postburn complications such as flexion contractures and boutonniere deformities.