What are the recommendations for outpatient management of hand burns?

Outpatient Management of Hand Burns

Initial Assessment and Cooling

For hand burns appropriate for outpatient management, immediately cool the burn with clean running water (15-25°C) for 5-20 minutes to limit tissue damage and reduce pain, then apply a non-adherent dressing and initiate early range-of-motion exercises to prevent contractures. 1, 2

• Remove all jewelry from the affected hand before swelling occurs to prevent constriction 1
• Cooling should only be performed if the burn covers <20% total body surface area (TBSA) in adults or <10% TBSA in children, and the patient shows no signs of shock 2, 1
• Monitor for hypothermia during cooling, particularly in children with larger burns 1

Criteria for Outpatient vs. Inpatient Management

Burns appropriate for outpatient care are superficial partial-thickness burns that do NOT involve the palm, do NOT cover >10% TBSA in adults (>5% in children), and do NOT involve circumferential injuries. 3, 2

Require immediate referral or inpatient management:

• All deep partial-thickness or full-thickness hand burns 2
• Burns involving the palm (these are particularly problematic and often require grafting) 3
• Circumferential burns of the hand or digits (risk of compartment syndrome) 2
• Contact burns of the hand in children (these frequently require >7 days hospitalization and 63% require surgical excision and grafting) 4
• Burns covering >10% TBSA in adults or >5% in children 2, 1
• Any hand burn with exposed tendons or joints 3

Wound Cleaning and Debridement

• Clean the wound with tap water, isotonic saline, or an antiseptic solution in a clean environment 2, 1
• Perform wound care with adequate analgesia (may require oral opioids or procedural sedation for initial debridement) 2, 1
• Do NOT break intact blisters, as this increases infection risk 1, 5
• If blisters are already broken or tense, debride carefully under sterile conditions 3

Dressing Selection and Application

Apply a non-adherent dressing (such as petrolatum-based gauze) covered with an absorbent secondary dressing, changed every 1-2 days initially. 1, 6

• There is insufficient evidence to recommend one specific dressing type over another 2
• Non-adherent dressings like petrolatum gauze (Jelonet, Xeroform) protect the wound while allowing exudate drainage 1, 2
• Avoid prolonged use of silver sulfadiazine on superficial partial-thickness burns, as it is associated with delayed healing 2, 7
• If silver sulfadiazine is used, apply once to twice daily to a thickness of approximately 1/16 inch 6
• Topical antibiotics should NOT be used routinely for prophylaxis, only for infected wounds 2, 1

Pain Management

• Prescribe oral analgesics (acetaminophen or NSAIDs for mild pain; opioids for moderate-to-severe pain) 1
• Cooling the burn and applying appropriate dressings can significantly reduce pain 2, 1
• Provide adequate analgesia before dressing changes 2, 1

Splinting and Positioning

Position the hand in the "safe position" (wrist extended 20-30°, metacarpophalangeal joints flexed 70-90°, interphalangeal joints extended, thumb abducted) using a splint applied immediately after initial wound care. 8, 3

• Splinting is vital to prevent contractures and preserve hand function 8
• The splint should be worn continuously except during exercises and dressing changes 8
• Avoid positioning that promotes flexion contractures (the "claw hand" deformity) 8, 3

Range-of-Motion Exercises

Initiate active and passive range-of-motion exercises within 24-48 hours of injury, performed 3-5 times daily, to prevent stiffness and contractures. 8, 3

• Early aggressive physical therapy is essential for optimal functional outcomes 8
• Exercises should include all joints of the hand and wrist 8
• Continue exercises throughout the healing process and into outpatient follow-up 8

Follow-Up Schedule

• Re-evaluate within 24-48 hours of initial treatment to assess wound progression and ensure proper healing 1, 3
• Continue follow-up every 2-3 days until epithelialization is complete 3
• Monitor for signs of infection (increasing pain, erythema, purulent drainage, fever) at each visit 1, 3
• Average outpatient follow-up for minor hand burns requires 2-5 visits 4

Critical Pitfalls to Avoid

• Do NOT apply ice directly to burns (causes further tissue damage and vasoconstriction) 1, 5
• Do NOT apply butter, oil, or home remedies (increases infection risk) 1, 5
• Do NOT underestimate contact burns in children—these often appear superficial initially but frequently require grafting 4
• Do NOT delay referral for palm burns—these are particularly difficult to manage and often require specialized care 3
• Do NOT allow the hand to rest in a flexed position—this leads to severe contractures 8, 3
• Do NOT use circumferential dressings without monitoring distal perfusion—check capillary refill and sensation at each visit 2

Indications to Convert to Inpatient Management

• Failure of wound to show signs of healing by 10-14 days (suggests deeper injury requiring grafting) 3
• Development of infection despite appropriate topical therapy 3
• Inability to maintain adequate range of motion due to pain or patient non-compliance 8, 3
• Progressive deepening of the burn (conversion from partial to full-thickness) 3