Preventing web space contractures in hand burns

Dr Dinuksha De Silva1, Dr Aruna Wijewardena1

1Royal North Shore Hospital, Sydney, Australia


Hand burns are a common injury – they are involved in 42-80% of all burn injuries (van der Vlies et al. 2017, Kamolz et al. 2008), and can have a devastating impact on function and quality of life. A major contributor to this impact is web space scar contracture. It is the most frequent indication for reconstructive surgery after a hand burn (van der Vlies 2017), and a number of techniques have been described in the literature for web space contracture release. The mainstays for preventing this are supervised passive motion protocols and compressive garments (Fufa, Chuang & Yang 2014). However, can we optimise acute surgical management to help prevent web space contracture?

Here we present our experience at a tertiary burns centre in Sydney using a protocol initially described by Dr Chandini Perera (Burns and Plastic Surgeon, Sri Lanka). This technique involves grafting dorsal hand and finger burns without grafting the web spaces. We avoid grafting interdigital skin, as it contains a continuation of glabrous skin similar to that of the palm. A period of 21 days from injury is observed without operating on web space skin.

This surgical case series of hand burns outlines functional and cosmetic outcomes at follow up. Following the aforementioned protocol, we have been able to obviate the need for post-burn reconstructive surgery for web space contracture.

1. Fufa, DT, Chuang, SS & Yang JY 2014, ‘Postburn Contractures of the Hand’, Journal of Hand Surgery, vol. 39, no. 9, pp. 1869-1876.
2. Kamolz, LP, Kitzinger, HB, Karle, B & Manfred, F 2008, ‘The treatment of hand burns’, Burns, vol. 35, pp. 327-337.
3. van der Vlies, CH, de Waard, S, Hop, J, Nieuwenhuis, MK, Middelkoop, E, van Baar, ME, van Zuijlen & PPM 2017, ‘Indications and Predictors for Reconstructive Surgery After Hand Burns’, J Hand Surg Am, vol. 42, no. 5, pp. 351-358.


Dinuksha is a surgical SRMO in the Burns and Plastics Department at Royal North Shore Hospital in Sydney.

Immersive Virtual Reality in Occupational Therapy practice as a non-opioid analgesic during burn wound care procedures.

Mrs Amber Jones1, Miss Erin Molloy1, Associate Professor Paul Gray2,  Emeritus Professor Jenny Strong1, Mrs Sue Laracy1

1Occupational Therapy, The Royal Brisbane & Women’s Hospital, Herston, Brisbane, Australia, 2Professor Tess Cramond Multidisciplinary Pain Service, The Royal Brisbane & Women’s Hospital, Herston, Brisbane, Australia


Introduction: For daily burn wound-care procedures, opioid analgesics alone are often insufficient (1-3). Often, burn injured patients experience uncontrolled pain during dressing changes leading to poorer physical and psychological outcomes (1-3). Virtual reality’s (VR) immersive, entertaining effects are useful for redirecting attention away from painful treatment experiences (1-3). With the rapid and continuous changes in technology, low-cost, feasible and effective options for VR are now readily available but minimally implemented. It is the aim of this study to determine if low cost, immersive VR in a burn injured cohort provides a valuable adjunct to opioid analgesics during wound-care procedures.

Method: A single-case experimental, multiple baseline design will be used across subjects. The multiple baseline design involves the measurement of multiple persons both before and after the use of VR and will allow the research team to make inferences about behaviour change (4). Transitions of each subject from no VR use to VR use will establish a baseline for intra-subject comparison. Numerical pain and anxiety scores pre, during and post wound-care procedure will be recorded along with quantified opioid use and wound care procedure duration. Patient and staff experiences will be obtained using descriptive questionnaires.

Results: Data will be visually analysed for changes in mean, level, slope, variability, latency and for consistency in patterns.

Discussion: If VR is found to decrease pain and anxiety during burn wound care, its wider integration in patient care will be an important next step in burn patient management.

1. Dascal, J., et al., Virtual Reality and Medical Inpatients: A Systematic Review of Randomized, Controlled Trials. Innov Clin Neurosci, 2017. 14(1-2): p. 14-21.
2. Kipping, Rodger, Miller & Kimble (2012). Virtual reality for acute pain reduction in adolescents undergoing burn wound care: a prospective randomised controlled trial. Burns, 38 p.650-657
3. Motta, Bucolo, Cuttle, Mill ,Hilder, Miller, Kimble (2008). The efficacy of an augmented virtual reality system to alleviate pain in children undergoing burns dressing changes: a randomised controlled trial. Burns, 34 (6) pp 803-808
4. Ottenbacher, K.J., Introduction to Single System Designs for Neurorehabilitation Research. Neurorehabilitation and Neural Repair, 1997. 11(4): p. 199-206.


Erin Molloy is a Senior Occupational Therapist working at the Professor Stuart Pegg Adult Burns Unit at the Royal Brisbane & Women’s Hospital. She is currently completing her PhD through the University of Queensland.

Burns Contractures Causing Ingrown Nails: A Case Series of Two Patients.

Dr Jenaleen Law1, Dr Aruna Wijewardena1, Dr Shane O’Neill1

1Royal North Shore Hospital, St Leonards, Australia


Introduction: Ingrown nails (onychocryptosis) occurs when the nail plate pierces the lateral nail fold and penetrates into the skin as a result of trauma, mechanical, or anatomical factors. It can cause inflammation or infection in the surrounding skin and interfere with the performance of daily activities. Ingrown nails typically affect the toes but can also affect the fingers. This case series describes two patients who developed ingrown fingernails following severe hand burns.
Cases: A 42-year-old gentleman suffered 43% TBSA deep dermal flame burns to his face, neck, and bilateral upper and lower limbs in a factory explosion. A 33-year-old gentleman suffered 33% TBSA deep dermal burns to his face and all four limbs in the same incident. Both patients required escharotomies for circumferential upper limb burns which were later debrided and covered with skin grafts. They underwent reconstruction to correct contractures of the palms, webspaces, and fingers. They also developed contractures causing the glabrous skin of the finger pulps to retract onto the dorsal surface of the fingers, towards the proximal nail folds. The resultant nail bed distortion lead to ingrown fingernails, which caused severe pain and required surgical treatment.

Conclusion: To the best of our knowledge, this is the first case series of ingrown fingernails following hand burns. It is postulated that the burns contractures distorted the nail bed and lead to the development of problematic ingrown fingernails. We hope this presentation will increase awareness and prompt further reporting of the functional long-term sequelae and management of hand burns.


Unaccredited Burns and Plastics Registrar at Royal North Shore Hospital, Sydney.

A systematic review to investigate outcome tools currently used for patients who have sustained hand burn injuries and to map the psychometric properties of the outcome measures identified from the literature across the ICF

Miss Andrea Mc Kittrick1, Professor Louise Gustafsson2, Emeritus Professor Jennifer Strong1

1Royal Brisbane And Women’s Hospital, Herston, Australia, 2School of Allied Health Sciences, Griffth University, Nathan QLD


Severe burn injuries are devastating for patients, resulting in life long complications of pain, scarring and disfigurement and psychological damage. The psychological impact and after-effects of sustaining a severe burn injury have been widely explored in the literature. Pain across the spectrum of burn care is dynamic and complex, changing over time. There are a myriad of co- morbidities that can interfere in the recovery process, for example, acute pain, chronic pain, pruritus and sleep disruption. Scars resulting from a burn injury have physical and psychological sequela that can impact and influence many aspects of routine daily life for the burn survivor. With advancements in health care delivery there has been a reduction in severe burn injury mortality (1% of all adult burns admissions in Australia and New Zealand [2013-2014] compared to 1.6% in [2009-2010]). However with increasing survival rates, in high income countries as reported by the World Health Organization (WHO), there have been increasing rates of morbidity. The focus of health care research in burn injuries has thus shifted to reflect on quality of survival versus quantity of survival.

Although hand burns represent a small Total Body Surface Area (TBSA) percentage, hand burns are classified as severe burn injuries that require the advanced skills and interventions that are provided at specialised burns centres thus meeting the criteria for referral to these centres. Patients with hand burns have increased care needs due to the difficulty they experience in personal activities of daily living while burn dressings are in place. In addition to patients who sustain burn injuries to the hands alone, hands are rarely spared in patients with TBSA burn injuries of greater than 60%. Interruption to the function of the hand resulting from a severe burn injury impacts on the patient’s participation in daily life and also on the ability to engage and interact with the surrounding environment. Therefore the primary aim of this systematic review is to investigate outcome tools currently used for patients who have sustained hand burn injuries and to map the psychometric properties of the outcome measures identified from the literature across the ICF.


Andrea is a senior Occupational Therapist working at the Royal Brisbane and Women’s Hospital in Brisbane. She has worked in burn care in Australia for over 12 years. This systematic review is part of her PhD candidature investigating outcome measures for severe hand burn injuries.


ANZBA is a not for profit organisation and the peak body for health professionals responsible for the care of the burn injured in Australia and New Zealand. ANZBA encourages higher standards of care through education, performance monitoring and research.

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