CASE REPORT Forty-Year Follow-up of Full-Thickness Skin Graft After Thermal Burn Injury to the Volar Hand

CASE REPORT

Our patient presented in January 1976 as an otherwise healthy 15-month-old child with third-degree burns to the volar hand, including the left index, long, and ring fingers that occurred 7 days before the consultation. The patient originally sustained third-degree burns to the hand after opening the oven door, climbing up, and placing the hand on a hot stovetop burner (Fig 1). At the time of presentation, there were no systemic sequelae of the burn and the blisters were intact. Acute management involved topical Silvadene application to the burned area. The patient was scheduled to follow-up with the surgeon regularly to assess need for future surgery. In May 1976, contractures of the left index, long, and ring fingers had developed and surgery was scheduled.

Figure 1. Burn injuries to flexural areas of the left volar hand in January 1976.

The patient was reexamined in October 1976 (Fig 2).

Figure 2. Photograph of the hand after follow-up in October 1976 showing scar maturation.

Transverse incisions were made to release the contractures and protect the neurovascular bundles on the left index, long, and ring fingers. It was noted that the dense scar caused shortening of the flexor tendon sheath of the same fingers. The defects were similar in size, but the contracture was most significant on the long finger. After the release, a full-thickness skin graft was taken from the left inguinal area. The graft took over the tendon and completely covered the defect. The patient was not cooperative at the dressing change 1 week later and required general anesthesia with ketamine.

The patient had excellent function until June 1987 (11 years later) when noted to develop progressive scar contracture at the age of 12 years (Fig 3). In August 1987 (Fig 4), the contractures were incised and a full-thickness skin graft was placed. There was extensive involvement around the neurovascular bundles, with the ulnar digital nerve of the index finger having the most involvement. Neurolysis of the neurovascular bundles of both digits and a repeat full-thickness skin graft from the right inguinal area were performed. The inguinal region was the donor site to avoid grafting skin bearing hair. Follow-up appointments after this surgery showed full range of motion and use for activities of daily living. There were no repeat incidents of contracture.

Figure 3. Hand in June 1987 with progressive contracture.

Figure 4. Hand at the time of surgery in August 1987.

RESULTS

Forty years after initial burn injury, our patient has well-healed scars without any signs of repeat contracture (Fig 5). Functionally, his hand is unhindered for his activities of daily living. Current examination shows full range of motion for digital extension (Fig 6) and gripping (Fig 7). His current occupation requires heavy gripping and lifting.

Figure 5. Patient's volar hand 40 years after initial burn injury.

Figure 6. Patient's hand with full digital extension.

DISCUSSION

Current literature lacks consensus regarding superiority of full-thickness versus partial-thickness skin grafts for burn contracture reconstruction.^2-4 The texture and color of volar hand skin are unique compared with other body skin and make donor selection difficult. Arguments for partial-thickness grafting suggest a decreased risk of palmar hyperpigmentation and less pain.^2-4 Full-thickness grafts have decreased recurrence of contracture.^3,5,6 These grafts also have increased capability for full flexion and extension of the hand and require less reoperation.^5,6 The increased pliability prevents functional hand deficits compared with partial-thickness grafts.⁷

Figure 7. Patient's hand with digital flexion.

Prior studies established factors improving skin graft survivability up to 3 years.^8-10 No study to date has followed a full-thickness skin graft for burn contracture reconstruction 40 years from the initial injury. The outcome strengthens arguments for the long-term durability of full-thickness skin grafting in hand burn injury. This case demonstrates that contracture release and soft-tissue reconstruction return adequate function to the hand even after significant thermal injury.