Digital Escharotomy: Time to update our technique?

Dr Sonia Hartog1, Dr Tim T. Wang

1Royal North Shore Hospital, St Leonards, Australia

Abstract:

Escharotomy plays a recognised role in maintaining the viability of extremities affected by circumferential burns. Indication and technique of digital escharotomies remain an area of contention, with requirement and practice differing between institutions. An early cohort study suggested that digital escharotomy was associated with a three-fold increase in finger salvage (20.8 vs. 7.1%).1 This however, has not since been replicated. The objective of this systematic review is to summarise the best evidence for technique in digital escharotomies.

Current Emergency Management of Severe Burns (EMSB) course and Clinical Practice Guidelines from Agency for Clinical innovation show digital escharotomies to be performed on the radial side of fingers and ulnar side of thumb.2 Radial-ulnar neurovascular differences exist in the digits. The radial digital nerve is larger in the index finger, ulnar digital nerve is larger in the thumb whilst the opposite is true for the digital arteries.3 Majority of authors currently recommend assessment of digital perfusion after hand escharotomy and if necessary, performing mid-lateral incisions on ulnar side of fingers and radial side of thumb as this avoids potential injury to the dominant digital nerves in surface used in fine pinch grip.4,5,6

Based on the above, we would propose amending ACI Clinical Practice Guidelines’ digital escharotomy recommendations.

References
1. Salisbury, R.E., Taylor, J.W. and Levine, N.S., 1976. Evaluation of Digital Escharotomy in burned hands. Plastic and Reconstructive Surgery, 58(4), pp.440-443
2. New South Wales Agency for Clinical Innovation – Escharotomy for Burns patients 2nd edition (2019) https://aci.health.nsw.gov.au/__data/assets/pdf_file/0003/162633/Escharotomy-for-Burn-Patients.pdf
3. Ortiz R, Westenberg R.F., Langhammer C.G., Knaus W.J., Chen N.C., Eberlin K.R. Nerve diameter in the hand: a cadaveric study. Plastic and Reconstructive Surgery Global Open. 2019 Mar;7(3).
4. Sheridan R.L, Hurley J, Smith M.A, Ryan C.M, Bondoc CC, Quinby W.C, Tompkins R.G, Burke J.F. The acutely burned hand: management and outcome based on a ten-year experience with 1047 acute hand burns. Journal of Trauma and Acute Care Surgery. 1995 Mar 1;38(3):406-11.
5. Schulze S.M., Weeks D., Choo J, Cooney D, Moore A.L., Sebens M, Neumeister M.W., Wilhelmi B.J. Amputation following hand escharotomy in patients with burn injury. Eplasty. 2016: 16.
6. Shelby R.D., Thakkar R.K., Bjorklund K.A. Upper Extremity Escharotomy and Fasciotomy. Operative Dictations in Pediatric Surgery 2019 pp. 465-468. Springer, Cham.


Biography:

Sonia is a Resident currently undertaking training at Royal North Shore Hospital. She studied Medicine at UNSW, Sydney.

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