Evaluation of Postburn Hand Function after Early Excision and Skin Grafting versus Delayed Skin Grafting; A Randomized Clinical Trial

1-In the early excision and grafting group, decision for operation was generally made within 72-hours of admission. In operating room, under general anaesthesia, tourniquets were applied for all patients to control bleeding. The depth at which punctuate bleeding occurred after tangential (layered) excision was used as a final criterion of burn depth. If burn injury remained superficial to the extensor paratenon, the burn was judged to be confined to the cutaneous tissue and the patient was included in the study. If the burn was extending to the extensor tendons, the patient was excluded from the study. Then, after irrigation and careful homeostasis, the tourniquet was inflated again and meshed split-thickness skin was transported to the wound and fixed; after dressing, the tourniquet was deflated. Following skin grafting, all hands were splinted in the anti-deformity position. 2-In delayed excision group, dressing was carried out until spontaneous separation of eschar. All hands were subjected to vigorous irrigation by saline and application of antimicrobial ointments in the form of betadine or nitrofurazone. Nutrition was emphasised, intravenous antibiotics for hospitalized cases were started according to the smear and culture result, which was taken if any sign of infection (cellulites, abnormal discharge, fever, severe pain or poor progression) occurred. Skin grafting was applied when healthy granulation tissue existed. Spontaneous separation of burn eschar and formation of healthy granulation tissue occurred in a range of 13 to 23 days post-burn with an average of 16 days. In the operating room under general anaesthesia and sterile condition, excess granulation tissue was removed to reach a suitable bed for graft, the meshed split-thickness skin from the healthy skin of thigh or trunk was transferred to the wound bed and fixed with non-absorbable monofilament suture material. Following skin grafting, all hands were splinted in the antideformity position. Commonly, the dressing was removed on the 5th postoperative day and if there was any sign of graft infection (fever, malodorous or draining wound), the dressing was changed sooner. 3-intensive physiotherapy( for all partcipants) Splinting and Immediate Physiotherapy: All burned hands included in the study were splinted at the time of admission in a dorsal static hand splint. The wrist joint was splinted at 300 hyperextension, the metacarpophalangeal (MCP) joints in 900 flexion, the interphalangeal (IP) joints in extension, and the thumb in abduction. The webs of fingers were kept in abduction. The hands were elevated above the level of the heart to minimize post-burn edema. Physiotherapy was consisted of, active assisted and active range of motion exercises. The frequency of exercises was 2-4 times daily with maximal repetition of 8-10 times for each exercises as reported in our previous work. Physiotherapy was also restarted one week after skin grafting in both groups.