Positioning and Splinting for the Prevention of Contractures

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Positioning and Splintingfor the Prevention of
Contractures
Burn Rehabilitation

• Michael A. Serghiou, OTR
• Shriners Hospitals for Children
• mserghiou_at_shrinenet.org

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INTRODUCTION

• The positioning of the burn patient is vital in
  bringing about the best functional outcomes in
  rehabilitation. It should begin immediately after
  the injury occurs and carried out until the scars
  from the last operative procedure are matured and
  all contractile forces cease to exist.

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INTRODUCTION

• Positioning should be designed for the specific
  individuals needs and be closely monitored and
  altered as the patients medical status changes.
  It should not compromise mobility and function as
  these will greatly affect the final functional
  outcome.

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INTRODUCTION

• The statement that the position of comfort is
  the position most likely to lead into
  contractures is applicable to every burn patient
  who has sustained a serious injury.

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Positioning Must Be Designed In A Way That It

• Maintains ROM
• Promotes wound healing
• Relieves pressure
• Protects joints, exposed
• tendons and new
• grafts/flaps

• Reduces edema
• Maintains joint alignment
• Maintains tissues elongated
• Prevents contracture
• formation

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When Positioning The Burn Patient The
Therapist/Nurse Should Consider The Following

• TBSA
• Depth of the burn
• Associated injuries
• Exposed tendons/joints
• Patients post operative status

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Complications Resulting From Prolong Or Improper
Positioning Include

• Pressure ulcers
• Nerve lesions
• Decreased ROM
• Joint malalignment

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POSITIONING FOR THE ENTIRE BODY
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HEAD

• Appropriate position Elevation with shock
  blocks. 12 inches tall blocks may achieve 30
  degrees elevation at the head of the bed.
• Special considerations Foot board to prevent
  sliding down the bed when head elevated.
• Shock blocks are only used with regular beds.

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NECK

• Appropriate Position Neck in midline with 10-15
  degrees of extension.
• Special Considerations Intubated patients may be
  positioned in neutral or in slight extension in
  maintaining good airway.
• Neck flexion contractures can lead to major
  cosmetic deformities, ventilatory
  difficulties,problems with salivation,
  vocalization and in extreme cases dislocation of
  the mandible.

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NECK

• Short mattress supine
• Roll behind the neck
• Head strap
• Never use a pillow for positioning the neck or
  the head of a burn patient.

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SHOULDER

• Appropriate Position 90 degrees abduction with
  15-20 degrees horizontal adduction and slight
  external rotation.
• Special considerations Monitor radial pulse and
  reposition the arm frequently to avoid
  compression of the brachial plexus which may lead
  to a neuropathy.Look for sensory (tingling,
  numbness) or motor (weakness,paralysis) deficits.

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ELBOW

• Appropriate Position Elbow in full extension
  with the forearm in neutral in slight supination.
  Avoid locking the elbow in extension.
• Special considerations Although flexion is the
  functional position, limitations develop more
  frequently in this position.

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WRIST and HAND

• Appropriate Position Wrist in 0-30 degrees
  extension, MCP joints in 70-90 degrees flexion,
  IP joints in full extension. The thumb is
  positioned in a combination of palmar and radial
  abduction maintaining the first web space in a
  stretched position.
• Special Considerations A dropped wrist not only
  leads to functional limitations, but can also
  cause compression to the median and ulnar nerves
  and disturb the venous return resulting in edema.

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WRIST and HAND

• Exposed tendons and joints should be positioned
  in a splint at all times without exceptions.
  During dressing changes of the hand with exposed
  structures the splint may be briefly removed
  while the affected structures are manually
  supported. The splint should be reapplied
  immediately after the dressing is completed.

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HIPS

• Appropriate Position Neutral rotation, 10-15
  degrees hip abduction and knee extension.
• Special Considerations The combination of hip
  flexion and abduction tightness can lead to hip
  dislocation. In patients with NO ventilatory
  problems the prone position facilitates hip as
  well as knee extension.

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KNEES

• Appropriate Position Full knee extension.
• Avoid locking the knee in full extension.
• Avoid elevation of the legs with knees
  unsupported.

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FOOT and ANKLE

• Appropriate Position The ankle joint is
  positioned in neutral/90 degrees dorsiflexion
  with the use of a foot board or a splint.This
  position should be maintained while the patient
  is lying in the prone or supine position.
• Special Considerations
• Plantar flexion and inversion lead to the
  equino varus
• deformity.
• Hard surfaces encourage venous stasis and
  can cause
• heel decubiti.

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ORTHOTICS/SPLINTING

• Introduction Orthotic and splinting devices are
  vital in burn rehabilitation as they are utilized
  throughout the patients recovery in obtaining
  appropriate positioning of the entire body.
• No matter how the therapist approaches
  splinting(materials, designs, application
  schedules) the goal is to bring about the best
  functional outcome at the completion of
  rehabilitation.

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ORTHOTICS/SPLINTING

• Introduction The burn therapist must be aware
  of the anatomy and kinesiology of the body part
  to be splinted prior to fabricating a splint or
  an orthotic device.

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Splinting Definitions

• Static splint Static or passive splints
  indicate that the affected joint or joints are to
  be immobilized or be movement restricted.
• Dynamic splint A dynamic splint is one that
  achieves its effects by movement and force. It
  is a form of manipulation. It may use forces
  generated by the patients own muscles or
  externally imposed forces using rubber bands or
  springs.

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Orthotics and Splinting Devices are used to

• Appropriately position a body part
• Support,protect and immobilize joints
• Prevent and/or correct deformity
• Protect new grafts and flaps
• Maintain and/or increase ROM
• Aid in edema and pain reduction
• Remodel joint and tendon adhesions

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Orthotic and Splinting Devices are used to

• Stabilize and/or position one or more joints
  enabling other joints to function correctly
• Assist weak muscles to counteract the effects of
  gravity
• Strengthen weak muscles by having the patients
  exercise against springs or rubber bands

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Splints and Orthotics should

• Not cause pain
• Be functional
• Cosmetically appealing
• Be easy to apply and remove
• Be light weight and low profile
• Be of appropriate materials
• Allow for ventilation

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Mechanical Principles of Splinting

• Pressure Reduce pressure by increasing the area
  of application.
• Mechanical Advantage (MA) Control parallel
  forces by increasing the MA.
• Use optimal rotational forces when mobilizing a
  joint by dynamic traction.Dynamic traction should
  be applied at a 90 degree angle.
• Torque Consider the torque effect on a joint.

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Mechanical Principles of Splinting

• Stabilize proximal normal joints to correctly
  mobilize distal affected joints.
• Consider the effects of reciprocal parallel
  forces when designing splints and placing straps.
• Increase splint strength by contouring the
  materials surfaces.
• Eliminate friction and splint migration.

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SPLINTING and POSITIONING for the ENTIRE BODY
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HEAD
FACE

• a) Transparent Face Mask (UVEX) -
  negative and positive molds required -
  prevents/ corrects scar hypertrophy -
  cosmetically appealing
• b) Opaque Face Mask - negative mold
  only - prevents scar hypertrophy
• c) Silicone Elastomer Face Mask -
  negative and positive molds required -
  prevents/ corrects scar hypertrophy
  
  

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HEAD
NOSE SPLINTS

• - nasal obturators- secure obturator to face
  mask or
• consider the mustache nostril splint-
  serial splinting

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HEAD

• EAR SPLINTS
• -Internal ear obturator
• -External oyster splint

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HEAD

• MOUNTH SPLINTS
• -Static -Dynamic Special
  Considerations -decreased vertical or horizontal
  opening -progressive stretching -drooling

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NECK

• Soft neck collar
• Anterior neck conformer (open,closed)
• Lateral neck conformerTorticollis splint
• Posterior neck collar with halo strap
• Special Considerations - neck contractures
  make for difficult
• intubation in case of an emergency.

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AXILLA/SHOULDER

• Axillary Pads
• Airplane Splints -custom made -SCOI
  Special Considerations -avoid stress
  on the brachial plexus

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ELBOW

• Static - anterior elbow conformer - 3-point
  extension
• Dynamic -flexion or extension

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WRIST

• Static - wrist cock-up volar/dorsal splint
• - palmar wrist splint with a thumb
• component
• - wrist deviation splints
• Dynamic - wrist flexion/extension/deviation

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HAND

• Static- burn hand splint
• - sandwich splint
• - resting pan splint
• - thumb web spacer
• (c-bar)
• - digital gutter splint

- stax splint - Murphy rings - figure 8 digital
splint - dorsal hand splint
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HAND

• Dynamic - MCP/IP joint flexion/extension
  splints - thumb outrigger - knuckle
  benders -spring flexion/extension splints
• Special Considerations -maintain angle of pull
  at 90 degrees

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HIP

• Hip spica
• 3-point extension hip splint

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KNEE

• Static- posterior knee conformer- 3-point
  extension
• Dynamic-infrequently utilized

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ANKLE/FOOT

• Static - Multipodus Splint System -
  dorsiflexion splint - plantarflexion splint -
  AFO
• Dynamic - AFO made by the orthotist

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Serial Casting

• Provides a prolong sustained stretch
• A fast, relatively inexpensive method of
  correcting burn scar contractures
• Flexion contractures of over 30 degrees respond
  well to casting
• Provides circumferential evenly distributed
  pressure
• It offers a successful alternative to dynamic
  splinting when patient compliance is an issue
  i.e. pediatrics