How should a post‑burn injury to the wrist and hand with loss of sensory and motor function of the volar (palmar) plate and reduced range of motion be managed?

Management of Post-Burn Wrist and Hand Injury with Sensory/Motor Loss and Reduced Range of Motion

This patient requires immediate referral to a specialized burn center for multidisciplinary evaluation and staged surgical reconstruction, as specialist management significantly improves both survival and functional outcomes in severe burn injuries 1.

Immediate Management Priorities

Acute Phase Assessment and Referral

• Urgently consult a burn specialist to determine severity and need for burn center admission 1
• Burns involving the hands represent a specific indication for specialist referral regardless of total body surface area (TBSA), as these anatomical areas require specialized care 1
• If direct burn center admission is not immediately possible, telemedicine consultation should be utilized to guide initial management 1

Compartment Syndrome Evaluation

• Assess for compartment syndrome immediately - deep burns causing volar plate dysfunction with sensory/motor loss suggest potential compartment syndrome
• If compartment syndrome is present, escharotomy should be performed urgently, ideally at a burn center by an experienced provider 1
• This is critical as delayed decompression leads to irreversible nerve and muscle damage

Surgical Reconstruction Strategy

Timing and Approach

The evidence strongly supports a staged approach to reconstruction:

Early Phase (After Wound Stabilization):

• Complete contracture release is the essential first step - this must include all contracted structures (skin, fascia, tendons) 2
• Early release is advisable (within 6 months) to avoid deep structure contracture and joint involvement 3
• Delayed treatment beyond 6 months significantly increases the likelihood of requiring flap coverage rather than simpler skin grafting 3

Coverage Selection Algorithm:

1. If exposed non-vascularized structures present (tendons, nerves, joints, bones) → Flap coverage required 3, 2
2. If vascularized bed present after contracture release → Skin graft sufficient 3, 2
3. For volar (palmar) contractures specifically: flaps are more commonly needed than for dorsal contractures 3

Functional Reconstruction Sequence

For Combined Nerve, Tendon, and Vascular Injury:

• Primary repair of all structures in a single stage is feasible when performed by experienced surgeons 4, 5
• Reconstruction priority: (1) vascular repair to restore circulation, (2) nerve repair, (3) tendon reconstruction 5
• For severe electrical burns with complete tissue loss, composite flaps incorporating nerve, tendon, and vascular elements can restore both protective sensation and motor function 4

Expected Functional Outcomes and Realistic Goals

Range of Motion Recovery

Based on recent high-quality evidence 6:

• Major joints (wrist) typically achieve near-complete functional ROM restoration
• Digital extension deficit is the most persistent problem, affecting approximately 27-29% of patients even at 12 months post-surgery 6
• Flexion recovery is generally more successful, maintained in 88.8% of patients 6
• Extension and flexion demonstrate largely independent recovery trajectories 6

Sensory Recovery

• With proper nerve repair, protective sensation can reach S2 level (recovery of some degree of two-point discrimination) by 6 months 4
• Complete median nerve transection requires 6+ months for meaningful sensory recovery 7

Critical Pitfalls to Avoid

1. Delayed diagnosis of carpal tunnel syndrome: Post-burn carpal tunnel syndrome is frequently overlooked with mean diagnostic delay of 137.5 days 8

   • Perform early electromyography if median nerve symptoms develop
   • Consider ultrasound for early detection when EMG unavailable 8

2. Incomplete contracture release: Partial release leads to recurrence - all contracted layers must be addressed 2

3. Inadequate post-operative rehabilitation: Intensive physiotherapy must begin in the second week post-surgery to achieve optimal functional results 2

   • Post-operative splinting for 10 days initially 2
   • Then aggressive ROM exercises

4. Underestimating the need for flap coverage: Attempting skin grafts over exposed tendons/nerves leads to graft failure 3, 2

Post-Operative Management Protocol

• Splinting: 10 days immobilization for skin grafts 2
• Physiotherapy initiation: Second week post-operatively 2
• Follow-up intervals: 3,6, and 12 months with objective ROM measurements 6
• Functional assessment: Use validated measures (QuickDASH, grip strength, two-point discrimination) 8

The key message: This injury pattern requires specialized burn center care with staged reconstruction - early contracture release (ideally <6 months), appropriate coverage based on exposed structures, and intensive rehabilitation to maximize functional recovery, though complete restoration of digital extension may remain elusive 1, 3, 6.