Overview
Definition:
Escharotomy is a surgical incision made through burned full-thickness eschar to relieve constriction and restore circulation
In hand burns, escharotomy is crucial for preserving function and preventing complications
The eschar, a toughened, inelastic dead tissue layer, can act as a tourniquet when it encircles a limb segment, impeding venous and arterial flow, and increasing tissue pressure
Identifying the need for escharotomy is critical in deep partial-thickness and full-thickness hand burns.
Epidemiology:
Hand burns constitute a significant percentage of all burn injuries, with specific incidence varying by geographic location and cause
Deep burns affecting the dorsum of the hand, fingers, or palmar surfaces are particularly prone to developing constricting eschar
The severity of hand burns, often requiring escharotomy, is directly related to the depth and extent of the thermal injury.
Clinical Significance:
Untreated constricting eschar on the hand can lead to severe morbidity including compartment syndrome, nerve compression, vascular compromise, ischemic contractures, and functional disability
Prompt escharotomy is vital to restore blood flow, prevent tissue necrosis, facilitate wound healing, and optimize functional outcomes
It is a cornerstone in the initial management of severe hand burns for surgical residents preparing for DNB and NEET SS exams.
Clinical Presentation
Signs Of Constriction:
Absent or diminished pulse distal to the burn
Paresthesias or numbness in digits
Cyanosis or pallor of the digits
Swelling of unburned distal tissues
Loss of capillary refill in fingertips
Inability to extend or flex digits actively or passively
Pain disproportionate to superficial findings
Progressive deepening of burn wound
Decreased motor function
Cool extremities.
Diagnostic Criteria For Escharotomy:
Clinical suspicion based on signs of compromised circulation in a circumferentially burned limb
Objective measures like Doppler ultrasound confirming reduced or absent distal flow
Measurement of compartment pressures, though less common in the hand compared to forearm, can be considered if compartment syndrome is strongly suspected
Deep partial-thickness or full-thickness burns encasing the hand or digits.
Associated Risks:
Risk of infection if performed late or inadequately
Potential for over-excision leading to excessive bleeding or further tissue loss
Damage to underlying neurovascular structures if not performed meticulously
Development of hypertrophic scarring or contractures at the incision sites if not managed properly post-operatively.
Diagnostic Approach
History Taking:
Mechanism of burn injury (flame, scald, electrical, chemical)
Time of burn
Depth and percentage of total body surface area (TBSA) burned, focusing on hand involvement
Patient's comorbidities
Previous surgical history
Allergies
Current medications
Symptoms of impaired sensation or circulation in the hand or digits.
Physical Examination:
Assess burn depth (superficial, partial-thickness, full-thickness)
Evaluate extent of burn on the hand and fingers
Palpate peripheral pulses (radial, ulnar) and assess capillary refill in digits
Assess sensation to light touch and pinprick in distal extremities
Assess active and passive range of motion of digits and wrist
Look for signs of compartment syndrome: tense swelling, pain, paresthesia, paralysis, pulselessness (late sign).
Investigations:
Arterial Doppler ultrasound to assess distal perfusion
Pulse oximetry on digits
If compartment syndrome is highly suspected, direct compartment pressure monitoring can be considered, though it is technically challenging in the hand
Routine blood work (CBC, electrolytes, coagulation profile) for pre-operative assessment.
Management
Indications For Escharotomy:
Circumferential deep partial-thickness or full-thickness burns of the hand or digits causing signs of vascular compromise
Presence of impending or established compartment syndrome
Inability to achieve adequate distal perfusion despite optimal positioning and fluid resuscitation
Impaired sensation or motor function suggestive of nerve compression by eschar.
Escharotomy Technique:
The standard incision is a linear cut along the mid-palmar line on the dorsum of the hand, extending from the metacarpophalangeal (MCP) joint proximally and distally to the base of the proximal phalanx or further as needed
For circumferential burns involving the digits, incisions are made along the mid-lateral lines, taking care to avoid major neurovascular bundles located dorsally and volarly
Incisions should extend through the entire thickness of the eschar down to the subcutaneous fat or fascia
Hemostasis is achieved by direct pressure or cautery
Post-incision, the eschar will separate, and bleeding may occur from superficial vessels
control by pressure
Fascial incisions are usually not necessary in the hand unless compartment syndrome is severe.
Wound Care Post Escharotomy:
Apply sterile dressings liberally impregnated with antimicrobial ointment to the escharotomy sites
Maintain hand elevation
Frequent assessment of distal perfusion, sensation, and motor function
Administer appropriate analgesia
Begin early range of motion exercises as tolerated, once stable
Consider early surgical debridement and grafting if full-thickness eschar is extensive and impairs wound healing.
Timing Of Escharotomy:
Escharotomy should be performed urgently once indications are met
Delay can lead to irreversible tissue damage
In the operating room under adequate anesthesia is preferred for definitive assessment and management.
Complications
Early Complications:
Hemorrhage from the escharotomy site
Infection of the incision or underlying tissues
Nerve injury or damage to tendons
Over-excision leading to excessive tissue loss
Failure to adequately relieve constriction.
Late Complications:
Impaired wound healing
Contractures at the escharotomy sites
Hypertrophic scarring
Functional deficits of the hand and fingers
Chronic pain
Infection with subsequent osteomyelitis.
Prevention Strategies:
Meticulous surgical technique avoiding injury to vital structures
Adequate hemostasis
Prompt wound care with appropriate dressings and antimicrobial agents
Early initiation of physical and occupational therapy
Careful monitoring of distal perfusion and neurological status
Early definitive closure with skin grafting when indicated.
Prognosis
Factors Affecting Prognosis:
Depth and extent of burn
Promptness of escharotomy
Presence of associated injuries (e.g., inhalation injury, fractures)
Patient's age and comorbidities
Adequacy of wound closure and rehabilitation
Development of complications like infection or contractures.
Outcomes With Treatment:
With timely and appropriate escharotomy, the risk of vascular compromise and compartment syndrome is significantly reduced, improving the chances of preserving hand function
Early intervention leads to better outcomes in terms of range of motion, sensation, and overall hand dexterity
Successful escharotomy, followed by appropriate wound management and rehabilitation, can prevent long-term debilitating sequelae.
Follow Up:
Regular follow-up is crucial to monitor wound healing, assess for signs of infection, manage scar formation, and guide physical and occupational therapy
The rehabilitation phase is critical for regaining optimal hand function and requires a multidisciplinary approach, including burn specialists, surgeons, therapists, and patients.
Key Points
Exam Focus:
Recognize clinical signs of circumferential hand burn constriction
Understand indications for escharotomy in hand burns
Know the specific anatomical landmarks for escharotomy incisions on the hand and digits
Differentiate between escharotomy and fasciotomy indications
Importance of early intervention to prevent compartment syndrome and vascular compromise.
Clinical Pearls:
Always assess distal pulses and capillary refill in circumferentially burned digits
Use Doppler to confirm diminished flow if clinical signs are equivocal
Make incisions along the line of maximal compromise, often the mid-dorsal aspect for the hand and mid-lateral for digits
Be prepared for bleeding and manage it promptly
Consider early grafting if the eschar is full-thickness and extensive.
Common Mistakes:
Delaying escharotomy due to uncertainty or underestimation of the severity
Making incisions too shallow or not through the full thickness of the eschar
Injuring superficial nerves or vessels
Inadequate post-operative wound care and rehabilitation
Failing to consider the need for fasciotomy in cases of deep muscle compartment involvement, though rare in the hand itself.