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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 204-209

A protocol advocating delayed surgical management of pediatric treadmill friction burn of the hand


Department of Surgery, Division of Plastic Surgery, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia

Date of Submission31-Mar-2020
Date of Decision30-Apr-2020
Date of Acceptance10-May-2020
Date of Web Publication02-Jul-2020

Correspondence Address:
Adnan Ghazi Gelidan
Department of Surgery, Division of Plastic Surgery, King Khalid University Hospital, King Saud University, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JNSM.JNSM_28_20

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  Abstract 


Introduction: Treadmills are common exercise machine used in households. The high-speed running pad can result in serious injuries to children's hands in the form of friction burns. These friction burns can be severe enough to require surgical intervention and prolonged wound care, frequently resulting in hypertrophic scarring and functional contracture. Materials and Methods: Retrospective data were collected for all pediatric patients who underwent surgical procedure for digit contracture secondary to treadmill friction burn between January 2017 and October 2019. Collected data included age, sex, percentage of burn, number of digits involved, duration of nonsurgical conservative treatment, course of surgical treatment, joints involved, degrees of joint flexion, and skin graft donor sites. Results: A total of 13 patients with a mean age of 4.77 years underwent delayed surgical correction of digit flexion contracture secondary to hypertrophic scar that involved the metacarpophalangeal joint, proximal interphalangeal joint, or distal interphalangeal joints that involved release of contracture full thickness skin graft (FTSG), and Kirschner (K-wire) fixation. Middle and ring fingers were the most commonly affected, with the left hand more involved than the right (9:4). Conclusion: Pediatric friction treadmill burn injury is a rising public health issue. The victims are mainly children younger than 10 years of age. The volar hands and digits are most frequently affected. Resulting flexion contracture will significantly affect hand function. In our series, delayed release of contracture, FTSG, and K-wire fixation was a treatment protocol which resulted in excellent preservation of hand function and minimal complication.

Keywords: Friction burn, hand, surgical management, treadmill


How to cite this article:
Gelidan AG. A protocol advocating delayed surgical management of pediatric treadmill friction burn of the hand. J Nat Sci Med 2020;3:204-9

How to cite this URL:
Gelidan AG. A protocol advocating delayed surgical management of pediatric treadmill friction burn of the hand. J Nat Sci Med [serial online] 2020 [cited 2020 Aug 12];3:204-9. Available from: http://www.jnsmonline.org/text.asp?2020/3/3/204/288824




  Introduction Top


With the increased public awareness about weight and exercise, more people are becoming health conscious and are choosing to exercise regularly, especially at the convenience of their home. Choosing from a variety of indoor sports machines and health equipment available in the market, people often pick treadmills as the easiest and most practical machine for home-based exercise and fitness.[1] Used progressively, treadmills are highly beneficial for adults wanting to maintain a healthy lifestyle; however, they may pose a serious hazard for children under the age of 2 years. Playful children and toddlers on exploratory mode, watching their parents exercising, are at risk for injuries. As many as 25,000 children globally sustain exercise-related injuries per year.[2],[3] We see more cases of hand injury, in the form of friction burns as a result of children inserting their hand in the moving treadmill conveyor belt. The degree of friction burns depends on the speed of the treadmill at the time of injury and whether the injury was witnessed or not. The type of management protocol followed is crucial to avoid negative sequela.[4] Majority of the friction burn incidents involve the upper extremity, with the hand, palm, and fingers being the most common sites.[5],[6],[7] Variable burn degrees are observed; however, surgery is most likely required for deeper burns. Surgery could be done as acute, subacute, or in a delayed fashion once flexion contracture develops. However, in general, management varies from nonsurgical wound care as an outpatient in the wound care clinic to immediate debridement and full thick skin grafting (FTSG) with an aggressive postoperative course of physio and physical therapy.[5],[8],[9],[10]

We would like to demonstrate the result of the protocol we used in managing hand friction burn injury . It involves an initial nonsurgical wound care till complete wound healing is achieved to reduce the possible risk of neurovascular bundle injury during acute debridement due to the thin and fragile nature of the children's skin, with the possibility of FTSG partial take if done acutely, that might lead to residual or some flexion contracture due to the healing by secondary intension and that is considered a failure and might need another surgical release. Surgical intervention is offered when the contracture started to develop in the follow-up course, which is the case in most of the deeper burns. The procedure consists of scar release, Z-plasty, and skin graft digit fixation, followed by aggressive physio and physical therapy courses.[11],[12],[13]


  Materials and Methods Top


After obtaining the local IRB approval, medical records of all children who underwent surgical procedures for treadmill injury at King Khalid University Hospital were retrospectively reviewed. Collected patients' demographics included age, sex, involved areas, presence of an adult during the accident, number of digits involved, duration of the nonsurgical management, duration until surgical treatment, degree of finger flexion, number of involved joints, type of surgical procedure, and location of the skin graft [Table 1] and [Table 2]. Postoperative range of motion (ROM), Metacarpophalangeal joint (MCPJ) Range 40° of extension – 100° of flexion, Proximal interphalangeal joint (PIPJ) Range 0° full extension – 90° of flexion, Distal interphalangeal joints (DIPJ) Range 0° full extension – 75° of flexion.
Table 1: Demographic information

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Table 2: Degrees of flexion and surgical protocol

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Surgical procedure

All procedures were performed by the author in an elective setting under general anesthesia [Figure 1] and [Figure 2]. After inflating the tourniquet, the procedure was started by releasing the flexion contracture at the area of maximum tension in a transverse fashion (over PIPJ initially, adding DIP, or MCP release if a full extension is not accomplished with the initial PIPJ release). The release was extended until the full extension of the finger, and the joint was accomplished at all joint levels. In one case, a Z-plasty at the level of the joint involved was added to release linear skin contracture distal to the joint [Algorithm 1]. A single Kirschner wire (K-wire) (0.8–1 mm) was inserted in a longitudinal fashion crossing DIPJ and PIPJ, and occasionally, MCPJ to maintain it in full extension at 180° for the duration of the K-wire placement, Intraoperative X-rays were done to confirm the K-wire placement. FTSG was harvested from the groin of the ipsilateral limb to cover the resulting defect. The skin grafts were sutured in place using a 5/0 absorbable suture. All wounds and skin grafts were dressed using Vaseline gauze and protective dressing. All patients had full above-elbow cast to avoid accidental slab or cast removal. The first dressing was done after 5 days at which all skin grafts were inspected for viability. The dressing was then switched to daily until skin graft is matured and completely healed. K-wires were removed at 3–4 weeks after surgery and physiotherapy is started thereafter with active ROM followed by passive ROM three times a week over a period of 1.5 months, and also, the instruction was given to the parent to continue physiotherapy at home [Figure 3] and [Figure 4] [Algorithm 1].
Figure 1: Contracture of the ring finger from treadmill friction burn

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Figure 2: Case of treadmill friction burn involving the index, middle, and rig finger treated with Z-plasty only to correct flexion contracture

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Figure 3: (a-c) Preoperative picture of flexion contracture of the middle and ring fingers a-p, lateral, and oblique. (d) Scar release of the middle finger at the distal interphalangeal joint, proximal interphalangeal joint. (e) Release scar of the ring finger at the proximal interphalangeal joint. (f) Full release of both digits. (g and h) Maintaining of full extension position of the middle and ring fingers with 0.8 mm K-wire. (i-k) Full-thickness skin graft applied over the resulted defect after full correction. (l) X-ray confirmation of adequate K-wire placement

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Figure 4: (a-c) Peroperative picture anterior, oblique and lateral of flexion contracture. (d and e) Surgical release of the metacarpophalangeal joint, proximal interphalangeal joint. (f-h) Fixation of the middle and ring fingers in full extension with K-wire. (i) X-ray confirmation of K-wire placement across the distal interphalangeal joint, proximal interphalangeal joint

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  Results Top


Between January 2017 and September 2019, 13 cases were identified (nine males and four females) at a mean age of 4.76 years (2.5–10). The left hand was involved in nine cases, while the right in four. The proportion of supervised: non supervised injuries is 11:2. Child injuries caused when a child hand caught by the treadmill conveyor belt and caused full-thickness burn that most commonly involved the hand area with total body surface area <1%. All children had a late presentation at a mean duration of 14 months (4–48). (If all children had a late presentation, then you can have the algorithm above have a path for early presentation and treatment. You did not look at these in this study.) A total of 27 digits were involved in addition to a one web space [Figure 5]. The middle and ring fingers were the most commonly involved (11 each), while the thumb was involved in one and the index in four cases. No little finger involvement was observed in our group [Table 1]. There was a variable degree of joint flexion contracture at the PIP and MCP. Three cases had three digits operated at the same time, while seven cases had two digits. One patient required Z-plasty without a skin graft. The mean follow-up period was 5.2 month.[7],[8] Flexion deformity was corrected fully in all patients [Figure 6]. Partial skin graft loss was observed in one patient who was treated with dressing changes and physiotherapy without observing any flexion contracture.
Figure 5: Flexion contracture thumb, index finger, and first web space. (a and b) preoperative pictures. (c and d) Immediate postoperative

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Figure 6: One-year follow-up of case of friction burn. (a) Full extension. (b) Full flexion. (c) Hyperpigmentation of the skin graft with complete correction of flexion deformity

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[Table 2] summarizes friction burn locations and the degree of flexion contractures. In all cases, we use the Kirschner wires not more than 4 weeks. In the all cases, we use different degrees of digit based on the child injuries. Most of injuries go with a surgical procedure and we used the skin graft technique used. In most of the cases, we used the left groin skin for grafting.


  Discussion Top


The use of household treadmills has spread over the past decades, as they are easy, inexpensive, and practical home alternative for fitness. Coincidentally, reports have shown increased treadmill-related injuries, particularly friction burn among children.[1],[2],[3],[4] The frequency of these injuries among children is likely to be underreported, as many patients with minor injuries do not seek medical help. Prevention and safety is the key to reduce this kind of burn injury.[6],[9],[14] Mismanaged injuries might lead to a full-thickness burn that when allowed to heal alone may result in flexion contracture deformity in the hand and digits, which could have a significant negative impact on the hand function, particularly for pediatric patients who present late.[7] Marshall and Lourie in 2003 reported 14 cases of treadmill digit injuries and concluded that 4 days is the crucial time for the success of nonsurgical treatment that includes aggressive wound care and splinting. After 4 days, the chance of requiring surgical intervention is significantly higher.[10] Goltsman et al. reported 298 cases of treadmill-associated injury, 93% involved the hands, and 49% required skin grafting.[4] Friedrich et al. advocate acute surgical debridement and skin grafting or such injuries claiming superior functional outcomes, reducing the need for reconstruction surgery.[15] Acute surgical management (debridement and grafting within few days) is rarely done for treadmill injuries since it is usually mixed second- and third-degree burn injury. Hence, one has to wait at least for the second-degree part to heal. However, we believe that acute surgical debridement and skin graft of the digits with deep burn puts the neurovascular bundle at risk of injury due to the very thin nature of skin in the pediatric age group even at the palm and digit areas. Subacute surgical management (debridement and grafting at 2 weeks after the injury) is done in many centers. Han et al. treated 16 children with this protocol and one had graft failure. Advantage of this protocol is less cost and less time to complete healing. Disadvantage includes higher risk to injury to digital nerves (which you cannot assess well in children, there unable to understand or describe the nature of numbness, and adapt to it), and lower percentage of full graft take because of wound colonization. Given this information, our protocol focuses on delayed management (leaving the wound to heal with contracture and then perform surgery) after failing of conservative trial period. The main aim of this study was to demonstrate the value of the described standardize surgical protocol that had the advantage of completely resolving the contracture deformity and restoring the maximum hand function with less injury risk to the nerves and vascular bundle and better graft take. The disadvantage is more time to complete the healing. In the current study, male pediatric patients have more treadmills hand injuries as compared to female pediatric patients, and the average age of injuries in all the cases is ~ 4.7 years, similar to other published studies.[8],[10],[14] Similar to what have been reported, in our series, the volar surface of the hands and digits was the most common injured, especially in the left hand [6],[7] with the index and middle finger most commonly affected.[7] In cases of superficial burn, daily dressing and early physiotherapy with night supports are used to avoid surgical intervention if possible.[16] However, in the cases with deep injuries, after failed nonsurgical treatment trial, we often recommend surgical contracture release and the use of full-thickness skin graft. Although many earlier studies have described the need for skin graft after the deep treadmill-related burns, only few described a surgical protocol to treat such injuries that resulted in complete correction of the flexion deformity and return of the full ROM without significant morbidities.[17],[18] The treatment decision in hand treadmill burn injuries varies among surgeons. While many advocate acute debridement and skin grafting with partial thickness skin graft or FTSG that might result in residual flexion contracture due to resulting scar after the split-thickness skin graft healed or partial healing of FTSG that might require another stage of scar release in the future to establish full ROM, others described using a protocol similar to our protocol which includes a trial period of nonsurgical treatment and aggressive physiotherapy, followed by managing the residual deformities with similar surgical technique.[7],[10],[11] We believe that Z-plasty is an ideal option for linear contracture distal or proximal to the involved joint. In our current study, we used FTSGs in almost all the cases due to the toddlers' treadmill friction burn hand injuries, more than the Z-plasty technique, a similar finding reported in the previous study that majority of severe injuries require skin grafting.[15]


  Conclusion Top


Pediatric friction treadmill burn injury is a rising public health issue due to the rising use of home-based exercise machines. The victims are mainly children younger than 10 years of age. Upper limbs, particularly the volar hands and digits, are most frequently affected. Delayed presentation and poor initial management can result in flexion contracture deformity that will significantly affect the hand function. Many surgical and nonsurgical treatment options are available. Our study supports the protocol which delays surgical treatment until after flexion contracture develops yet results in excellent functional outcomes.

Acknowledgment

This work is supported by the college of medicine research center deanship of scientific research in King Saud University, Riyadh, Saudi Arabia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Carman C, Chang B. Treadmill injuries to the upper extremity in pediatric patients. Ann Plast Surg 2001;47:15-9.  Back to cited text no. 1
    
2.
Abbas MI, Bamberger HB, Gebhart RW. Home treadmill injuries in infants and children aged to 5 years: A review of Consumer Product Safety Commission data and an illustrative report of case. J Am Osteopath Assoc 2004;104:372-6.   Back to cited text no. 2
    
3.
U.S. Consumer Product Safety Commission. Document #5028: Prevent Injuries to Children from Exercise Equipment. Washington, DC: U.S. Consumer Product Safety, Commission; 1999.   Back to cited text no. 3
    
4.
Goltsman D, Li Z, Connolly S, Meyerowitz-Katz D, Allan J, Maitz PK. Pediatric treadmill burns: Assessing the effectiveness of prevention strategies. Burns 2016;42:1581-7.   Back to cited text no. 4
    
5.
Banever GT, Moriarty KP, Sachs BF, Courtney RA, Konefal SH Jr, Barbeau L. Pediatric hand treadmill injuries. J Craniofac Surg 2003;14:487-90.   Back to cited text no. 5
    
6.
Maguiña P, Palmieri TL, Greenhalgh DG. Treadmills: Apreventable source of pediatric friction burn injuries. J Burn Care Rehabil 2004;25:201-4.   Back to cited text no. 6
    
7.
Collier ML, Ward RS, Saffle JR, Edelman LS, Morris SE, Lundy C. Home treadmill friction injuries: A five-year review. J Burn Care Rehabil 2004;25:441-4.   Back to cited text no. 7
    
8.
Juang D, Fike FB, Laituri CA, Mortellaro VE, St Peter SD. Treadmill injuries in pediatric population. J Surg Res 2011;170:139-42.   Back to cited text no. 8
    
9.
Marchalik R, Rada EM, Albino FP, Sauerhammer TM, Boyajian MJ, Rogers GF, et al. Upper extremity friction burns in the pediatric patient: A 10-year Review. Plast Reconstr Surg Glob Open 2018;6:e2048.   Back to cited text no. 9
    
10.
Marshall J, Lourie MM. Pediatric hand friction burn injury secondary to treadmills. J Pediatric Orthopedics 2003;23:407-9.   Back to cited text no. 10
    
11.
Lohana P, Hemington-gorse S, Potokar T, Wilson YT. Pediatric injuries due to home treadmill use: An emerging problem. Ann R Coll Surg Engl 2012;94;121-3.   Back to cited text no. 11
    
12.
Sorkin M, Cholok D, Levi B. Scar management of the burned hand. Hand Clin 2017;33:305-15.   Back to cited text no. 12
    
13.
Sunil N, Ahmed F, Jash P, Gupta M, Suba S. Study on surgical management of post burn hand deformity. J Clin Diagn Res 2015:9;C06-10.  Back to cited text no. 13
    
14.
Jeremijenko L, Mott J, Wallis B, Kimble R. Paediatric treadmill friction injuries. J Paediatr Child Health 2009;45:310-2.   Back to cited text no. 14
    
15.
Friedrich JB, Muzaffar AR, Hanel DP. Pediatric hand friction burns from treadmill contact. Hand (N Y) 2007;2:188-93.   Back to cited text no. 15
    
16.
Borschel GH, Wolter KG, Cederna PS, Franklin GA. Acute management of exercise treadmill-associated injuries in children. J Trauma 2003;55:130-4.   Back to cited text no. 16
    
17.
Wong A, Maze D, La Hei E, Jefferson N, Nicklin S, Adams S. Pediatric treadmill injuries: A public health issue. J Pediatr Surg 2007;42:2086-9.   Back to cited text no. 17
    
18.
Han T, Han K, Kim J, Lee G, Choi J, Lee J, et al. Pediatric hand injury induced by treadmill. Burns 2005;31:906-9.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

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