Management

1
Management Rehabilitation of theBurned Hand

• CPT Ted Chapman, OTR/L
• Assistant Chief,
• Darnall Army Medical Center
• Fort Hood, TX

2
Objectives

• Discuss complexities of the human hand
• Describe prevalence of hand injuries and ABA
  referral criteria
• Discuss management of 1st and 2nd degree
  superficial partial thickness hand burn (PTB)
• Discuss management of 2nd degree deep PTB and 3rd
  degree full thickness (FT) hand burns
• Discuss management of 4th degree burns to the
  hand

3
Objectives

• Discuss Burn Pathology Skin/Scar Tissue related
  to Hand Rehabilitation
• Describe purpose of hand burn therapy
  prevention and management of contractures
• Describe positioning splinting techniques
• Discuss common hand burn complications with
  emphasis on the deep palmar burn

4
Complexities of the Human Hand Injury
Prevalence
5
Complexities of the Human Hand

• Delicate and complicated multisystem organ that
  provides precise sensory information motor
  execution

6
Complexities of the Hand Wrist

• Dependent on
• 27 bones
• 30 joints
• 33 muscles/tendons
• 3 peripheral nerves
• intricate vascular system
• variety of support structures...

7
Protective Covering of the Hand

• Unique qualities of the skin facilitate hand
  function
• Dorsum fine, supple, mobile and easily
  separated from the deep fascia
• Volar thick, hairless, inelastic, rich in
  sensory receptors, and supplied with sweat
  glands.

8
Hand Injury Prevalence

• Most frequent injured part of the body
• 2 yr study at USAISR revealed 89 of 568 pnts
  suffering large burns (20 TBSA) had UE
  involvement
• 60 of OIF/OEF suffered hand burns

9
American Burn Association Referral Criteria
Injuries requiring a Burn Center referral

• 2nd degree burns 10 TBSA
• Burns to face, Hands, feet, genitalia, perineum,
  major joints
• 3rd degree burns

• Electric injury (lightning included)
• Chemical burns
• Inhalation injuries
• Burns accompanied by pre-existing medical
  conditions
• Burns accompanied by trauma, where burn injury
  poses greatest risk of morbidity or mortality
• Burns to children in hospitals without pediatric
  services
• Patients with special social, emotional or
  rehabilitative needs

10
Epidermal Burn 1st Degree

• Inconvenience Seldom clinically significant
• Epidermis only No risk for hypertrophic
  scarring or contracture
• Pain Redness Analgesia and early elevation
  AROM exercises
• Heals peel

11
Superficial PTB 2nd Degree

• Pain, blisters, moist, capillary refill
• Entire epidermis and portion of dermis
• Analgesia and early elevation AROM exercises

12
Superficial PTB 2nd Degree

• Uninjured dermis epidermal appendages at risk
• Avoid trauma, edema, and infection Follow-up
  immediately if cellulitis occurs

13
Epidermal Wound Healing
14
Superficial PTB Post Burn Day (PBD) 28
15
Deep Partial Thickness 2nd Degree

• Skin graft may improve functional cosmetic
  outcome
• high moderate risk for hypertrophic scarring
  or contracture
• Heals spontaneously in 2-3 weeks via scarring
  epidermal wound healing

16
Full Thickness 3rd Degree

• Entire thickness of epidermis dermis

• Decreased pain blisters
• Dry
• Absent capillary refill

17
Full Thickness 3rd Degree

• Heals by contracture epithelial ingrowth from
  edges, or
• Excision Skin grafting

18
Sub dermal burns 4th Degree
19
Sub dermal 4th Degree
20
4th degree Digit Amputations
21
Hand Wound Care Dressing
cream
2x2 gauze roll
surgi-net to digit hand
full ROM
staples
22
Electrical Hand Burns

• Skin internal structural injury (subdermal 4th
  degree)

• Most destructive type of burn (high voltage)
• 3-12 of all burns are electrical

23
UE Electrical Burn Tx

• OR debridement
• Record m. n. integrity
• Anti-spasticity type splint FDS / FDP FPL
• Maintain tendon length
• Nerve regeneration vs. Tendon transfers

24
Burn Pathology andSkin Scar
Related to Hand Rehabilitation
25
LD50
26
New Millennium Challenges

• age extremes
• inhalation injury
• wound healing in large burns
• restoration of function
• ADLs
• Work
• Leisure

27
Anatomic regions w/ highest incidence of burn
scar contractures (BSC)

• Kraemer, Jones, Deitch, LSU, JBCR, 1988
• 101 BSC in 839 patients
• Hand 35
• Head/Neck 30
• Axilla 21
• 80 of contractures developed in areas that had
  skin grafts

• Dobbs Curreri, USAISR, J Trauma, 1972
• 143 BSC in 681 patients
• Hand 45
• Elbow 20
• Shoulder 19
• depth extent of areas burned, then the
  probability severity of BSC upon healing the
  burn

28
Primary Obstacles to Restore Function

• Cardio-vascular Edema (acute chronic)
• Neurological neuropathies pain
• Integumentary burn scar contracture deformity
  hypertrophic scarring

29
Acute Edema w/i Intrinsic Muscles
30
Pathology Chronic Edema
31
Neurologic System

• Peripheral Neuropathy
• Polyneuropathy unk 20 neurotoxicity
• Local Neuropathy
• electrical, splints, OR, bandages, tourniquet,
  HO, needle injections
• Burn Pain
• Greatest obstacle to burn rehab efforts
• Pain Anxiety Management
• allow express rest periods encouragement
• inform pnt what your going to do pain meds on
  board

32
Neurologic System
33
Integumentary System

• Burn Scar Contracture (BSC)
• lack of sufficient extensible tissue to permit
  full range of motion
• Deformity
• Cosmesis
• Hypertrophic r Keloid Scarring
• Skin Problems Itching and Blisters
• Thermoregulation
• Sensory changes
• Ultraviolet Light Sensitivity melanin

34

• Position of comfort will become the
• Position of contractures

35
Intrinsic Minus a.k.a. Claw Hand Deformity
36
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37
Central Slip Rupture 2/2 Deep Dorsal Finger Burns

• Ischemic necrosis
• Rupture central slip
• Swan or boutonnière
• Consider IP static extension splints or K-wire
  fixation 2-4 wks

38
PIP joint deformity
39
Minimal Hypertrophic Scarring
40
Severe Hypertrophic Scarring
41
Skin Extensibility of the Dorsal Digit
4 ¼ inches
5 ¼ inches
42
Effect of Stress Collagen

• Tensile Stress
• Fibroblast Cell

Collagen Fibrils
Cell DNA
Produce Collagen
43
Burn Rehabilitation Hand

• Burn Rehab Purpose
• The prevention and treatment of burn scar
  contracture deformity and hypertrophic scarring
• Maintain function or potential for function
• Improve appearance

44
Burn Hand Evaluation Primary Aspects

• ROM goniometers, functional ROM
• Edema volumetric, figure 8
• Strength dynamometer, pinch gauge, MMT, BTE
• Sensation moving/static 2 PD, semmes weinstein
• Burn Wound Assessment Burn est. diagram
• Location
• Extent
• Depth
• Function DASH, FIM, AMA, Jebson-Taylor

45
UE Hand Function Assessment Tools

• Disability of the Arm, Shoulder and Hand (DASH)
  Questionnaire
• Jebson-Taylor Hand Function Test
• Greenleaf AMA Impairment Rating (4th ed.)
• Functional Independence Measure (FIM)

46
Burn Depth Determination
Clinical Importance

• Wound care
• E G
• Outcome

1st
2nd
3rd
47
Burn Location Distribution
30 TBSA
30 TBSA
Extent of Burn 20 TBSA Increased
complications
48
Location of Hand Burn
49
Tx Objectives

• Prevent cellular and structure destruction
• Prevent contracture deformity
• Control scar symptoms
• Maximize functional independence
• Maintain strength endurance
• Education reintegration
• Maximize functional independence

50
FunctionalROM 1st,

• Strength 2nd

51
Burn Patient Treatment

• Time of day a.m.
• Frequency of treatment
• Duration of treatment
• Intensity of Treatment
• Post tx position splint PRN

52
Principles of Positioning Splinting

• Decrease edema
• control inflammation
• Protect healing structures
• restrict motion
• Prevent contracture deformity
• maintain ROM
• Correct contracture deformity
• allow tissue growth / remodeling
• Maximize hand function
• Improve prehension / dexterity grasp

53
Protective / Corrective / Assistive Positioning
Splinting
54
Decrease Edema

• Prevent Cell Destruction Hand Deformity
• Position hand above Elbow, and Elbow above
  Heart
• maintain end organ perfusion at zone of stasis
• avoid intrinsic minus hand

55
Intrinsic Plus thumb opposition, MCP flexion, IP
extension
56
Post Operative Hand Splinting
57
Splinting with Kirschner-wire
58
Post-op Wound vac for hands
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Dorsal Hood Mobility
61
TERT of hrs?
62
Thumb Web Space C Bar
Splint
63
Thumb Web Space Elastomer Putty Splint
64
Static Splinting using ext fix and/or K-wire
65
Thumb Web Space Static Progressive Splint
66
Thumb Opposition Static Progressive Splint
Dorsal Thumb Scar Contracture
67
Digit Serial Casting
68
SF Deformity Prevention
69
Indication dorsal hand burn contracture with
MCP flx to DPC/PPC MP IP Static Progressive Flexion Splint
70
Static Progressive Finger
Flexion Splint
71
Hand Static Progressive Inelastic Splinting
72
L SF Cobra Style MCP Flexion Static Progressive
Splint
73
Swan Neck Deformity Conservative Treatment

• Silver Ring Splint
• Rupture central slip
• Lateral bands sublux dorsally

74
Patient Motivation Tolerance

• Instruct patient and family early
• Extensive time involved w/ self ROM
• Unforgiving treatment regiments
• Required for good results

75
Burn Scar Assessment

• Vascularity
• Pliability
• Height
• Compliance

76
Normal Scarring
77
Hypertrophic Scarring

• Immature Scars
• Red
• Raised
• Rigid
• Mature Scars
• Pale
• Planar
• Pliable

78
Hand Web Space Strapping Splint
79
Self-Adherent Elastic Bandage

• Coban Tape

80
Who needs compression garments?

• No pressure support required
• burn heals
• Pressure support may be required
• burn wound heals 10 - 14 days (Blacks Asians)
• Any race or age advised to use pressure
• burn wound heals in 14 - 21 days
• Pressure support is mandatory
• all burn wounds that require 21 days to heal
• Deitch EA, Wheelaham TM, Rose MP Hypertrophic
  burn scars Analysis of variables. J Trauma
  198323895-898

81
Customized Garments

• Out-pnt clinic
• skin can tolerate shear forces
• styles colors
• 2 - 3 sets
• esp. children
• wash daily

82
Deep PT/FT Palmer Burn Case Reviews
83
Deep Palmer Burn
84
Volar Thumb Palm Burns

• Thumb adduction contracture
• Cupping of the palm

85
PBD 2 months
86
PBD 4 months
87
PBD 6 months Release FTSG
FTSG
88
PBD 8.5 months
89
PBD 2 months
90
PBD 4 months
91
SF Ray
PBD 6 months
92
PBD 8.5 months
93
POD 4 integra
POD 7 AROM
94
POD 4 for stsg to integra
95
Palm Anti-Contracture Splint/Cast
Cupping Deformity
96
STSG over Integra
97
Reconstruction Common Sequellae of Hand Burns

• Burn Scar Contracture deformities
• Web space dorsal hooding syndactyly, esp.
  1st web space
• Boutonniere deformity, esp. 5th SF digit
• SF MCP ext, PIP/DIP flx w/ digit supination
• Toe to hand transplant
• Palm contracture, esp volar thumb

98
1st Web Space Release
99
PBD 1 year
PBD 4 months
100
References

• ABA Postgraduate Course B, The Challenge of the
  Burned Hand, 31st Annual Meeting, 1999.
• Barret J, Herndon D Color Atlas of Burn Care,
  London, 2001, WB Saunders.
• Green DP Operative hand surgery, ed 3, New
  York, 1993, Churchill Livingstone.
• Chapter 55, The Burned Hand and Upper Extremity,
  Roger E. Salisbury, George P. Dingeldein
• Richards R, Staley M Burn Care and
  rehabilitation principles and practice,
  Philadelphia, 1994, F.A. Davis Company.
• Achauer B, Burn Reconstruction, New York, 1991,
  Thieme Medical Publishers, Inc.
• Fess E, A History of Splinting To Understanding
  the Present, View the Past. J of Hand Therapy.
  April-June 200215(2) 97-131.

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Questions?