Clinical Profile and Acute-Phase Management Modalities of Pediatric Hand Burn: A Retrospective Study

Round 1

Reviewer 1 Report

This is a retrospective review of hand burn injuries presented in a large burn centre. authors are describing the issues and non standardized protocol they have in their burn centre and also the outcomes associated with larger burns when the hands are affected also. The introduction is too long and needs to be cut to at least 25% of the current size. It is unclear the methodology and the aim of the paper from the description in the manuscript. Data that has 0 value should not be presented in a bar chart graph. the focus of this paper should be on the hand burns only and maybe compared the outcomes when the hand burns are isolated with when the injuries are associated with burns > 15% TBSA.

The results are present also in the methods with the table 1 not explaining the types of the categories A, B, C. the discussions and the conclusion sjould be focused on the aim which needs to be more specific and narrow. Otherwise the manuscript as it stands now is an epidemiological profile of patients who sustained hand related burn injuries

Author Response

Comments and Suggestions for Authors

This is a retrospective review of hand burn injuries presented in a large burn centre. authors are describing the issues and non standardized protocol they have in their burn centre and also the outcomes associated with larger burns when the hands are affected also. The introduction is too long and needs to be cut to at least 25% of the current size. It is unclear the methodology and the aim of the paper from the description in the manuscript. Data that has 0 value should not be presented in a bar chart graph. the focus of this paper should be on the hand burns only and maybe compared the outcomes when the hand burns are isolated with when the injuries are associated with burns > 15% TBSA.

The results are present also in the methods with the table 1 not explaining the types of the categories A, B, C. the discussions and the conclusion sjould be focused on the aim which needs to be more specific and narrow. Otherwise the manuscript as it stands now is an epidemiological profile of patients who sustained hand related burn injuries

 

Answers to RW1

We wish to extend our appreciation to RW1  for the positive contributions and constructive criticism shown in the review of our article.

Within the scope of focusing on hand burns, the bar chart (Figure 2) was removed, and an abbreviation was applied in the Discussion section, considering the suggestions. Since our burn center is a referral center, it serves all major/minor burn patients. Thank you for your suggestions and comments for our study, which is planned to discuss the main features with an overview of hand burns. Within the scope you suggested, there were 343 patients with a TBSA range of 1-15% in our study, and we did not want to exclude hand burns in this burn range in our study.

Author Response File: Author Response.pdf

Reviewer 2 Report

This is a study on a very important aspect of burn care – hand burns. The author retrospectively analyses the outcome of 422 patients suffering from hand burns and describes the study cohort. The authors correctly analyse the present literature and raise several questions, that still remain to be answered. Unfortunately, most of these questions still remain unanswered after reading the manuscript. Therefore, the manuscript required major revisions.

Title: The authors name and title seem to be incorrect „Kayhan Gurbuz and MD“                                                                                                                                    

Abstract: The author presents outcome results as „Category A-C“ but does not introduce this classification in the abstract. It is recommended to omit this scoring system from the abstract and to just present VSS and functional outcome.

Introduction (line 73-75): „Deep partial-thickness and full-thickness burns are treated similarly with controlled excision of non-viable tissue with tangential excision and early skin grafting.“ => I would recommend to focus on the fact, that viable skin parts have to be preserved. In this context surgical techniques such as hydrosurgery should be mentioned. In additon enzymatic necrosectomy using bromelain or other agents should be mentioned (even though it may be „off-label“).

Introduction (line 81): „the thinner skin structure of children makes them more prone to full-thickness burns 81 than adults“ => this is not true in every child. Babies have thicker subcutaneous fat layers on the hand dorsum than adults or older children!

Material and methods (line 117): Table 2 is introduced in the text before table 1 => this should be changed.

Results (line 143): Table 1 should be revised. The categorisation A to C is the major result of the study and should therefore be presented in a seperate figure. Furthermore: the VSS is on item in the scoring system. Since Category A includes only patients with VSS 0-2 it is no surprise, that the mean VSS is 1.1, and the mean VSS in category B is 3.1 (definition of category B is VSS 3-8) ……

Results (line 181): The treatment algorithm is not a results and should be moved to the methods.

Results (line 184 – 186): „Repeated examinations were performed for evaluating the distal perfusions, Doppler USG controls, and pulse-oximetry at the patient's first hospitalization and in the first three days following, and necessary escharotomy/fasciotomy procedures were performed promptly in this period.“ => The authors should clearly describe their treatment algorithm. When do they allpy what kind of diagnostic measure? What are the indications for escharotomies or even fasciotomies.? Do the authors really wait for three days before escharotomies are performed?

Results (line 190): „early rehabilitation programm“ => what does „early“ mean, please give the exact time points (immediate, after two days ….???), What does rehabilitation program mean? Physical therapy, occupational therapy, splinting?? => since the rehab is of utmost importance in hand burns the authors should give mor information on their exact regimen.

Results (line 192): „soaking them in running water in the first 1 hour for 20 minutes“ => this is really questionable. Several studies show, that cooling of more that 2mins leads to deepening of burn wounds rather that a prevention. The authors should explain their algorithm.

Results (Line 194): Again: What does „early“ mean and what therapeutic measures are exactly applied to the patients.

Results (line 196): When (exact time point/frame) ist he second evaluation performed.

Results (line 204-210): „In cases where the depth of the burn is uncertain, the following procedures are performed after surgical cleaning of the wound: application of moist wound closure using local antibacterial agents (silver sulfadiazine), the use of skin substitutes, and dressing changes in 2-day periods, while it has waited for two to maximum three weeks, superficial partial-thickness burns heal spontaneously during this time STSGs were applied to the patients who did not heal, and debridement was completed during this period.“ => As I understand, the authors perform concervative treatment in clearly superficial partial burns and surgery in clearly full thickness and perform a „wait and see“ strategy over two weeks in deep partial thickness burns. Three aspects have to be adressed:

1. The use of silver sulfadizine => this is questionable since silver induces a pseudo eschar, that renders wound judgement impossible until the pseudo eschar is removed.
2. Why did the authors perform no skin grafting in deep partial burns in all category A patients and peformed skin grafting in deep partial thickness burns in all category B patients (see table 1) => is the functional outcome just a result of skin grafting?
3. Technical tool exist to llow an earlier judgement oft he burn depth. Would it be more reasonable to use one of these tools (such as laser-doppler, laser speckle..) and to earlier perform surgery

Results (line 215,216): Here, the authors mention that they use K-wires. The authors should provide information what they exactly do when. Immobilisation by K-Wires, Splinting, How long, when do they start physical therapy, etc.

Results (line 220): The use of flaps (groin flap) is not mentioned in table 1

Results (line 222-225): It should be mentioned that none of the patients in category A underwent skin grafting whereas all patients in Category B/C were grafted. Ist he functional outcome just a result of skin grafting? Can no „good“ results be achieved when skin grafting is required?

Results (line 229-231): This paragraph should be omitted. Since Category A only includes patients with VSS 0-2, caterory B includes VSS 3-8 and category C includes VSS 9-13, mean VSS scores of 1.1, 3.1 and 11.5 in categories A to C are no surprise.

Diskussion: The major weakness of the manuscript is that many questions are raised and most of them are not answered. The questions are:

• Timing of surgical necrosectomy (the manuscript lacks information on exact time points/time frames when necrosectomy is performed)
• The type of the skin grafts (split-/ full- thickness) (the authors only use split thickness skin grafting)
• The timing for a range of motion (the manuscript lacks information when the authors allow movement with conservative treatment and after skin grafting)
• The use of splinting/Kirschner wires (no information is given what the indications and time points/time frames for splinting and K-Wires are)
• The timing of surgical treatment (no information of exact time points/frames)
• The surgical procedures to be applied for the cases in which the exposed tendons
• Moreover, the use of dermal substitutes and post-operative positioning continues to be unresolved (do the authors appliy dermal substitutes at all => no information is given.

 

One more problem is, that the only difference between categories A to C are the severity of the injury (increases from A to C) and the necessity of skin grafting. The authors should discuss this in this section. Is the outcome just a result of the severity of the injury and of skin grafting or can treatment measures improve outcomes (a fact that is without any doubt but should be underlined by facts from the manuscript).

Discussion (line 266-276): This paragraph is redundant since it is likewise presented before.

Discussion (line 276-78): „In this study, the other anatomical sites burn accompanied to HBs in 90.0% of the cases consisted of the indicated HBs reported incidence range of 35% to 89% in past research. [3-5,6-8].“ => The correct comparison would be 27% (422/1580) HBs of all burn patients in the present study compared to 35% to 89% in past research.

Last, The manuscript would be significantly imroved if hand function would be measured using the DASH-score (a validated tool of disability in activities of daily living after upper extremity surgery).

Author Response

Comments and Suggestions for Authors

This is a study on a very important aspect of burn care – hand burns. The author retrospectively analyses the outcome of 422 patients suffering from hand burns and describes the study cohort. The authors correctly analyse the present literature and raise several questions, that still remain to be answered. Unfortunately, most of these questions still remain unanswered after reading the manuscript. Therefore, the manuscript required major revisions.

1. Title: The authors name and title seem to be incorrect „Kayhan Gurbuz and MD“                                                                                                                                    
2. Abstract: The author presents outcome results as „Category A-C“ but does not introduce this classification in the abstract. It is recommended to omit this scoring system from the abstract and to just present VSS and functional outcome.
3. Introduction (line 73-75): „Deep partial-thickness and full-thickness burns are treated similarly with controlled excision of non-viable tissue with tangential excision and early skin grafting.“ => I would recommend to focus on the fact, that viable skin parts have to be preserved. In this context surgical techniques such as hydrosurgery should be mentioned. In additon enzymatic necrosectomy using bromelain or other agents should be mentioned (even though it may be „off-label“).
4. Introduction (line 81): „the thinner skin structure of children makes them more prone to full-thickness burns 81 than adults“ => this is not true in every child. Babies have thicker subcutaneous fat layers on the hand dorsum than adults or older children!
5. Material and methods (line 117): Table 2 is introduced in the text before table 1 => this should be changed.
6. Results (line 143): Table 1 should be revised. The categorisation A to C is the major result of the study and should therefore be presented in a seperate figure. Furthermore: the VSS is on item in the scoring system. Since Category A includes only patients with VSS 0-2 it is no surprise, that the mean VSS is 1.1, and the mean VSS in category B is 3.1 (definition of category B is VSS 3-8) ……
7. Results (line 181): The treatment algorithm is not a results and should be moved to the methods.
8. Results (line 184 – 186): „Repeated examinations were performed for evaluating the distal perfusions, Doppler USG controls, and pulse-oximetry at the patient's first hospitalization and in the first three days following, and necessary escharotomy/fasciotomy procedures were performed promptly in this period.“ => The authors should clearly describe their treatment algorithm. When do they allpy what kind of diagnostic measure? What are the indications for escharotomies or even fasciotomies.? Do the authors really wait for three days before escharotomies are performed?
9. Results (line 190): „early rehabilitation programm“ => what does „early“ mean, please give the exact time points (immediate, after two days ….???), What does rehabilitation program mean? Physical therapy, occupational therapy, splinting?? => since the rehab is of utmost importance in hand burns the authors should give mor information on their exact regimen.
10. Results (line 192): „soaking them in running water in the first 1 hour for 20 minutes“ => this is really questionable. Several studies show, that cooling of more that 2 mins leads to deepening of burn wounds rather that a prevention. The authors should explain their algorithm.
11. Results (Line 194): Again: What does „early“ mean and what therapeutic measures are exactly applied to the patients.
12. Results (line 196): When (exact time point/frame) ist he second evaluation performed.
13. Results (line 204-210): „In cases where the depth of the burn is uncertain, the following procedures are performed after surgical cleaning of the wound: application of moist wound closure using local antibacterial agents (silver sulfadiazine), the use of skin substitutes, and dressing changes in 2-day periods, while it has waited for two to maximum three weeks, superficial partial-thickness burns heal spontaneously during this time STSGs were applied to the patients who did not heal, and debridement was completed during this period.“ => As I understand, the authors perform concervative treatment in clearly superficial partial burns and surgery in clearly full thickness and perform a „wait and see“ strategy over two weeks in deep partial thickness burns. Three aspects have to be adressed:

1. The use of silver sulfadizine => this is questionable since silver induces a pseudo eschar, that renders wound judgement impossible until the pseudo eschar is removed.
2. Why did the authors perform no skin grafting in deep partial burns in all category A patients and peformed skin grafting in deep partial thickness burns in all category B patients (see table 1) => is the functional outcome just a result of skin grafting?
3. Technical tool exist to llow an earlier judgement oft he burn depth. Would it be more reasonable to use one of these tools (such as laser-doppler, laser speckle..) and to earlier perform surgery

14. Results (line 215,216): Here, the authors mention that they use K-wires. The authors should provide information what they exactly do when. Immobilisation by K-Wires, Splinting, How long, when do they start physical therapy, etc.
15. Results (line 220): The use of flaps (groin flap) is not mentioned in table 1
16. Results (line 222-225): It should be mentioned that none of the patients in category A underwent skin grafting whereas all patients in Category B/C were grafted. Ist he functional outcome just a result of skin grafting? Can no „good“ results be achieved when skin grafting is required?
17. Results (line 229-231): This paragraph should be omitted. Since Category A only includes patients with VSS 0-2, caterory B includes VSS 3-8 and category C includes VSS 9-13, mean VSS scores of 1.1, 3.1 and 11.5 in categories A to C are no surprise.
18. Discussion: The major weakness of the manuscript is that many questions are raised and most of them are not answered. The questions are:

• Timing of surgical necrosectomy (the manuscript lacks information on exact time points/time frames when necrosectomy is performed)
• The type of the skin grafts (split-/ full- thickness) (the authors only use split thickness skin grafting)
• The timing for a range of motion (the manuscript lacks information when the authors allow movement with conservative treatment and after skin grafting)
• The use of splinting/Kirschner wires (no information is given what the indications and time points/time frames for splinting and K-Wires are)
• The timing of surgical treatment (no information of exact time points/frames)
• The surgical procedures to be applied for the cases in which the exposed tendons
• Moreover, the use of dermal substitutes and post-operative positioning continues to be unresolved (do the authors appliy dermal substitutes at all => no information is given.

 

19. One more problem is, that the only difference between categories A to C are the severity of the injury (increases from A to C) and the necessity of skin grafting. The authors should discuss this in this section. Is the outcome just a result of the severity of the injury and of skin grafting or can treatment measures improve outcomes (a fact that is without any doubt but should be underlined by facts from the manuscript).
20. Discussion (line 266-276): This paragraph is redundant since it is likewise presented before.
21. Discussion (line 276-78): „In this study, the other anatomical sites burn accompanied to HBs in 90.0% of the cases consisted of the indicated HBs reported incidence range of 35% to 89% in past research. [3-5,6-8].“ => The correct comparison would be 27% (422/1580) HBs of all burn patients in the present study compared to 35% to 89% in past research.
22. Last, The manuscript would be significantly imroved if hand function would be measured using the DASH-score (a validated tool of disability in activities of daily living after upper extremity surgery).

 

Answers to RW2

First of all, we wish to extend our gratitude to RW2 for the positive contributions and constructive criticism shown in the review of our article.

The following changes were made in the manuscript in accordance with the suggestions and comments of the distinguished reviewer:

A-1. The authors' name and title are corrected as Kayhan Gurbuz, MD, Mete Demir, MD

A-2. The scoring system for evaluating the movement/functional status of the hands, which the esteemed reviewer appreciated as the most critical finding of this study, has been introduced in the Abstract Section.

A-3. The study included a cohort of hospitalized pediatric patients with hand burns, as noted in the text. We sometimes perform enzymatic necrosectomy in outpatient hand burns, which make up most of our patients. The concept of hydro surgery has been added to the text.

A-4. This paragraph was deleted as part of the suggestion that the RW1 Entry is long and should be shortened. This action indirectly resolved the issue raised by the respected reviewer.

A-5. The suggested arrangement regarding the Table introduction has been made.

A-6. While making the necessary revision, the categorization from A to C in line with the recommendations is presented separately (Table 2).

A-7. The treatment algorithm is moved to the Materials and Methods section.

A-8,-9,-10,-11,-12. We explained that repetitive examinations took three days since the circumferential burns of the hand and upper extremity injuries accompanied major burns that are likely to lose perfusion with extensive fluid resuscitation. However, as stated in our recently published article,¹ escharotomy/fasciotomy procedure was applied within 8 hours to the latest 48 hours following the initial injury. Corrections were made in line with comments and suggestions in the treatment modalities segment.

1. Kayhan Gurbuz, MD, Mete Demir, MD, Abdulkadir Basaran, MD, Koray Das, MD, Most Prominent Factors Contributing to Burn Injury-Related Amputations: An Analysis of a Referral Burn Center, Journal of Burn Care & Research, 2021, irab219, https://doi.org/10.1093/jbcr/irab219

A-13,-16.

1. In line with the suggestions, the Silver Sulfadiazine antibacterial agent recommendation was removed from the text, leaving the comment to the reader.
2. When our results were re-examined, it was seen that eight patients who should have been evaluated in Category A were classified as Category B. Necessary corrections have been made.
3. In our clinic, burn depth assessment is performed by specialist physicians with at least six years of burn surgery experience within the possibilities available.

A-14. Kirschner wires were used for joint stabilization only in unstable exposed joints in HBs.

A-15. The suggested correction in the table has been made.

A-17. The paragraph in the Result section (line 229-231) has been omitted.

A-18. While moving to the Material Method section with its rearranged form, all possible adjustments were added to the Treatment Algorithm subsection in line with the suggestions.

A-20. The paragraph in the Discussion section (line 266-276) has been omitted.

A-21. Necessary adjustments were made in the discussion section (lines 276-78) in line with the suggestions of the esteemed reviewer.

A-22. We hope that the DASH-score (a validated tool of disability in activities of daily living after upper extremity surgery) that you suggested will be considered in our future studies since our analysis was designed retrospectively. The necessary data were loaded according to the previously created system.

Again, thank you very much for allowing us to revise our manuscript.

 

Author Response File: Author Response.pdf

Reviewer 3 Report

The manuscript suffers from a number of shortcomings which are summarized in the main suggestions below.

• Abstract includes mostly general statements; I suggest focusing on the study results and the main conclusions.

 

Main text

Material and Methods section

• I would suggest rewriting the inclusion and exclusion criteria as in some instances they refer to the same conditions, e.g., patients with superficial burn injury.

‘…Age groups were stratified as 0-4, 5-9, 10-14, and 15-<18 age groups to evaluate the 109 clinical outcomes of HBs treated conservatively and surgically according to the age 110 groups. In addition, the percentage of total body surface area burns (TBSA%) was divided 111 into 0-9, 10-19, 20-29, 30-39, 40-49, 50+ segments in the same context.’

• Stratification based on age is different in the text and in Table 1.
• Explain the choice of stratification in 6 different groups based on TBSA since it was not referred to in the results.

 

Results section

‘… the analysis was carried out on the remaining 1580 patients.’

• This study presents and analyses  data of 422 patients with hand burn.

 

• The tables should be numbered according to the order of data presentation, I suggest reversing the numbering of tables 1 and 2, as data presented in Table 2 are presented earlier in the text.
• Some information mentioned in the Results section and in the Discussion should be transferred to the Material and Methods, e.g., data regarding treatment algorithm.
• The discussion is chaotic, vague, focusing mainly on the general management of burns and little on the results of the study. The Discussion section needs to be better organized. I would suggest rewriting a more condensed version with clear references only to the data reported in the Result section. Previous studies that support or disagree with the present study should be mentioned.
• The conclusion section does not reflect the results of the study. I suggest rewriting and focusing only on study’s main findings.

Minor remarks

• The manuscript needs revision for language and grammar.

 

 

Author Response

Comments and Suggestions for Authors

The manuscript suffers from a number of shortcomings which are summarized in the main suggestions below.

Abstract includes mostly general statements; I suggest focusing on the study results and the main conclusions.

Main text

Material and Methods section

I would suggest rewriting the inclusion and exclusion criteria as in some instances they refer to the same conditions, e.g., patients with superficial burn injury.

‘…Age groups were stratified as 0-4, 5-9, 10-14, and 15-<18 age groups to evaluate the 109 clinical outcomes of HBs treated conservatively and surgically according to the age 110 groups. In addition, the percentage of total body surface area burns (TBSA%) was divided 111 into 0-9, 10-19, 20-29, 30-39, 40-49, 50+ segments in the same context.’

Stratification based on age is different in the text and in Table 1.

Explain the choice of stratification in 6 different groups based on TBSA since it was not referred to in the results.

Results section

‘… the analysis was carried out on the remaining 1580 patients.’

This study presents and analyses  data of 422 patients with hand burn.

The tables should be numbered according to the order of data presentation, I suggest reversing the numbering of tables 1 and 2, as data presented in Table 2 are presented earlier in the text.

Some information mentioned in the Results section and in the Discussion should be transferred to the Material and Methods, e.g., data regarding treatment algorithm.

The discussion is chaotic, vague, focusing mainly on the general management of burns and little on the results of the study. The Discussion section needs to be better organized. I would suggest rewriting a more condensed version with clear references only to the data reported in the Result section. Previous studies that support or disagree with the present study should be mentioned.

The conclusion section does not reflect the results of the study. I suggest rewriting and focusing only on study’s main findings.

Minor remarks

The manuscript needs revision for language and grammar.

 

 

We would like to thank RW3 for the contributions and constructive criticism shown in the review of our article.

In line with the suggestions of the esteemed reviewer, the necessary corrections were made in the Inclusion criteria subsection in the Material and Methods section.

Stratification of age groups was rearranged in Table 1.

Within the scope of focusing on hand burns and in line with the comments, TBSA stratification is removed from the Material and Methods section and Table 1.

The suggested edit in the results section has been carried out.

Table numbering has been rearranged according to the data presented.

The data about the treatment algorithm was moved to the Materials and Methods section in line with the recommendation.

 

Thank you again for allowing us to review our article.

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

The manuscript has significantly improved, however, some more changes are required. 

1. The manuscript still does not give information on the exact rehab programm. Do the authors yours splints/immobilize the hand after grafting? For how long? when do they start physical or occupational therapy in conservatively treated patients and after Surgery. (For example, after skin grafting we use immobilization using splints for 4 days. At day 4 we start physical therapy. Compression garments are applied after 10 days.......) A14 and A18
2. A19 has not been adressed "One more problem is, that the only difference between categories A to C are the severity of the injury (increases from A to C) and the necessity of skin grafting. The authors should discuss this in this section. Is the outcome just a result of the severity of the injury and of skin grafting or can treatment measures improve outcomes (a fact that is without any doubt but should be underlined by facts from the manuscript).
3. A18: The following quenstions are still not answered and should at least be discussed in the discussion: 
   1. Split thickness skin grafting versus full thickness skin grafts => what are the advantages and disadvantages and why did the authors decide for STSG. 
   2.  The timing for a range of motion (the manuscript lacks information when the authors allow movement with conservative treatment and after skin grafting (s.above)
   3. The use of splinting (no information is given what the indications and time points/time frames for splinting) How long are joints immobilzed?
   4. The surgical procedures to be applied for the cases in which the exposed tendons

Author Response

Comments and Suggestions for Authors

The manuscript has significantly improved, however, some more changes are required. 

1. The manuscript still does not give information on the exact rehab programm. Do the authors yours splints/immobilize the hand after grafting? For how long? when do they start physical or occupational therapy in conservatively treated patients and after Surgery. (For example, after skin grafting we use immobilization using splints for 4 days. At day 4 we start physical therapy. Compression garments are applied after 10 days.......) A14 and A18
2. A19 has not been adressed "One more problem is, that the only difference between categories A to C are the severity of the injury (increases from A to C) and the necessity of skin grafting. The authors should discuss this in this section. Is the outcome just a result of the severity of the injury and of skin grafting or can treatment measures improve outcomes (a fact that is without any doubt but should be underlined by facts from the manuscript).
3. A18: The following quenstions are still not answered and should at least be discussed in the discussion: 
1. Split thickness skin grafting versus full thickness skin grafts => what are the advantages and disadvantages and why did the authors decide for STSG. 
2.  The timing for a range of motion (the manuscript lacks information when the authors allow movement with conservative treatment and after skin grafting (s.above)
3. The use of splinting (no information is given what the indications and time points/time frames for splinting) How long are joints immobilzed?
4. The surgical procedures to be applied for the cases in which the exposed tendons

 

Answers to the comments and suggestions of RW2

We would like to present our pleasure to the esteemed reviewer for the constructive criticism and patience shown in the review of our article.

A-1. The following paragraph, edited on the recommendations of the esteemed editor, has been added to the discussion section:

‘’Generally, a splint is used for the first 6-7 days until the stitches or clips used in STSG fixation are removed. Immediately after this period, passive movements are continued with the physical therapy program, and active movements are started in the following days. After the patients are discharged, they are referred to the Physical Therapy and Rehabilitation Department. Besides, compression garments are applied during this period.''

A-2. The following paragraph, edited on the recommendations of the esteemed editor, has been added to the conclusion section:

‘’ In the study, only about 2% of patients in Category-A needed skin grafts, while this rate increased to 87% in Category-B. No result seriously interfered with the performance of activities of daily living in Category B patients who underwent skin grafting. We believe that skin graft applications also contributed to these noted outcomes.’’

A-3.

1., In the discussion section of the revised article, Line 244-245 uses meshless split-thickness skin grafting for dorsal hand burns, while lines 141-143 and 243-244 describes the use of full-thickness skin grafts for palmar burns with reasons.

2,3. Explained in A1

4. Exposed tendons are considered a 4th-degree burn and are beyond the scope of this study. Our preferred method in this situation is multi-branch treatment approaches and flap repairs in appropriate cases, with the necessary clinical consultations from the Hand Surgery-/Plastic and Reconstructive Surgery-Departments.

In line with the comments of the esteemed RW2, exposed tendons were included in the exclusion sub-section in the Materials and Methods section.

We should state that, in terms of licensing issues, reference 19 has been replaced by the open-access article.

Reviewer 3 Report

The authors have made appropriate changes and have improved the quality of the manuscript. I would recommend a few more minor revisions to this paper prior to publication.

• The conclusion section could be revised to flow better and include brief commentary on the main results instead of duplicating the last paragraph of the Results section.
  
  

Results section,  subsection 3.5. Outcomes of the treatment algorithm for hand burn injuries

 84% (n=355) of the cases were treated conservatively within this general treatment  algorithm framework.

• I would suggest spelling out a number when it occurs at the beginning of a sentence

 

Author Response

Comments and Suggestions for Authors

The authors have made appropriate changes and have improved the quality of the manuscript. I would recommend a few more minor revisions to this paper prior to publication.

• The conclusion section could be revised to flow better and include brief commentary on the main results instead of duplicating the last paragraph of the Results section.
  
  

Results section,  subsection 3.5. Outcomes of the treatment algorithm for hand burn injuries

 84% (n=355) of the cases were treated conservatively within this general treatment  algorithm framework.

• I would suggest spelling out a number when it occurs at the beginning of a sentence

 

Answers to the comments and suggestions of RW3

We would like to present our pleasure to the esteemed reviewer for the constructive criticism and patience shown in the review of our article.

The corrections in the conclusion section and the Result section, subsection 3.5., were made in line with the suggestions of the dear reviewer.