HAND CONFERENCE
HAND BURN INJURY
R E H A B I L I T A T I O N
joissalvadorptmd
GENERAL DATA
JPS
7/M
Filipino
® Handed
Roman Catholic
Grade 1 student
Payatas, Batasan Hills, Quezon City
PHYSICAL EXAMINATION
PHYSICAL EXAMINATION
ASSESSMENT
S/P Burn secondary to flame injury, hand ®
S/P Surgical release of flexion contracture (Z plasty),
5th digit ®
HAND BURN
SUPERFICIAL
BURN
Erythematous, pink or
red; irritated dermis;
“sunburn”
No blister; Dry surface;
Delayed pain; Tender
Minimal edema
Spontaneous healing in
3-5 days by desquamation
No scar formation
SUPERFICIAL
PARTIAL
THICKNESS
BURN
Bright pink or red;
Mottled red; Inflamed
dermis; Erythematous with
blanching and capillary
refill
Intact blisters; Moist or
glistening surface; Painful
and sensitive to light touch,
temp, air currents
Moderate edema
Slow healing by 7-10 days
Minimal scarring with
some residual discoloration
DEEP PARTIAL
THICKNESS
BURN
Mixed red, waxy white;
Blanching with slow
capillary refill
Broke blister, wet
surface; sensitive to
pressure but insensitive to
light touch or soft pin prick;
Hairs maybe intact
Marked edema
Slow healing up to 3-5
weeks
Excessive scarring
FULL
THICKNESS
BURN
White (ischemic), tan,
fawn, mahogany, black, red;
Hemoglobin fixation; No
blanching; Thrombosed
vessels; poor distal
circulation
Parchment like leathery,
rigid, dry; Anesthetic; Body
hairs pull out easily
Area depressed
Heals with skin grafting;
Scarring
SUBDERMAL
BURN
Charred
Subcutaneous tissue
evident; Muscle damage;
Neurological involvement
Tissue defect; heals with
skin grafting
Scarring
BURN WOUND
ZONES
1. COAGULATION
Irreversibly damaged
and skin death occurs
2. STASIS
Injured cells that may die
within 24-48 hours without
diligent treatment
3. HYPEREMIA
Site of minimal cell
damage and tissue recover
within several days with no
lasting effect
HAND BURNS
Frequently involved in
burn injury
Significantly impacts
functional aptitude
Complex problems
Deep burns with exposed
tendons/bones
Secondary contractures
and deformities
Chronic pain syndromes
HAND BURNS
American Burn Association Criteria for Admission to a
Burn Center:
Partial Thickness burn greater than Patient with burn and coexistent
10% of TBSA trauma (e.g. fractures)
Full thickness in any age group Patient who requires special social,
Burns that involves the hand,hand feet, emotional, or long term rehabilitation,
face, perineum, genitalia, or skin including cases involving suspected
overlying a major joint child abuse
Children with burns in hospital settings
Electrical burns including lightning
injury without qualified burn management
Chemical burns personnel or equipment
Inhalation injury
Burn injury in patient with preexisting
illness that could complicate
management
Committee on Trauma. Guidelines for Operations of Burn Units. American Burn Association, Chicago 1999, p 5
ACUTE PHASE
EDEMA
Major cause of claw
burn hand (intrinsic
minus position)
Persistent edema is
devastating because it
can result to “frozen
hand”
EXPOSED TENDONS
Dehydration
Denature
Subsequent rupture
EXPOSED TENDONS
Boutonniere Deformity
Dorsal hood ruptures
EXPOSED TENDONS
Swan Neck Deformity
Volar plate rupture
Intrinsic muscle
tightness
EXPOSED JOINTS
Joint capsule exposed
but not open
Joint capsule exposed
and open
Joint Subluxation
EXPOSED BONES
Periosteal dessication
WOUND CARE
DEBRIDEMENT
Mechanical
Hydrotherapy
Wet to Dry dressing
Enzymatic
Surgical
WOUND CARE
TOPICAL AGENTS FOR BURNS
WOUND CARE
SKIN GRAFT
Autograft (Human)
Xenograft (Animal skin)
Homograft/Allograft
(Cadaver)
Synthetic Dressing
(Biobrane)
Cultured Keratinocytes
ACUTE POSITIONING
Elevation
Active exercise
ACUTE POSITIONING
Joints Common Motions to be Suggested
Deformity stressed approaches
Hand Claw Hand (a.k.a. Wrist extension; Wrap finger
intrinsic minus MCP flexion; PIP separately
position) and DIP extension; Elevate to decrease
Thumb palmar edema
abduction Position in
intrinsic plus
position: MCP
flexion; PIP and
DIP extension;
Thumb in large
palmar abduction
ACUTE SPLINTING
Anti-Deformity Positioning
JOINTS POSITION
WRIST 20-30 deg extsn
MCP 60-90 deg flexion
PIP 10 deg flexion
DIP 5 deg flexion
THUMB Palmar abduction
ACUTE SPLINTING
Anti-Deformity Positioning
Resting Hand Splint
ACUTE SPLINTING
Resting Hand Splint
with Finger Separator
RANGE OF MOTION EXERCISES
Encouraged to do
active exercises of
involved body parts
Active assistive of
passive exercise should
be initiated if a patient
cannot fully achieve
active exercise
RANGE OF MOTION EXERCISES
“Active exercise should begin on the day of admission”
1. Ward RS: Physical Rehabilitation. In Carrougher, GI (ed): Burn Care Therapy. CV
Mosby, St. Louis, 1998, p 293
2. Grisby de Linde, L: Rehabilitation of the child with burns. In Tecklin, JS (ed): Pediatric
Physical Therapy, ed. 3 Lippincott, Philadelphia, 1999, p 468
3. Humphrey C, et al: Soft tissue management and exercise. In Richard, RL and Staley, MJ (eds):
Burn care and Rehabilitation: Principles and Practice. FA Davis, Philadelphia, 1994, p324
THERAPEUTIC MODALITIES
“ If burn wound are well healed, heating modalities
(e.g. paraffin, ultrasound) may be used to increase
the pliability of the tissue before exercise therapy”
1. Ward RS: The use of physical agent in burn care. In Richard, RL and Staley, MJ (eds):Burn care and
Rehabilitation: Principles and Practice. FA Davis, Philadelphia, 1994, p324
THERAPEUTIC MODALITIES
THERAPEUTIC
ULTRASOUND
Used to treat painful
joints and facilitate better
tolerance of range of
motion exercise
Has been applied with ice
massage to control
hypertrophic scarring
ULTRASOUND
THERAPEUTIC MODALITIES
PARRAFIN WAX BATH
Decreases joint
discomfort and lubricates
skin
Paraffin temperature
should be lowered to 116
to 118 deg F to prevent
burning of the skin
PARAFFIN WAX BATH
“ The technique of applying paraffin to the part being
mobilized and allowing 20 minutes of sustained
stretch has been very rewarding”
Halm PA, et al: Burn Rehabilitation. In Delisa J (eds ) Physical Medicine & Medicine.
Principles and practice ed 3. Lippincott Ch 85 p 1867
THERAPEUTIC MODALITIES
ELECTRICAL STIMULATION AND TENS
Electrical Stimulator,
using an alternating
currents, is helpful in
treating tendon adherence
to underlying scar tissue
TENS is useful for
treatment of various pain
problems, and as adjunct
to ROM exercises
THERAPEUTIC MODALITIES
INTERMITTENT COMPRESSION UNIT
Valuable in reducing
edema in extremities,
particularly the
edematous hand
ACTIVE AND PASSSIVE EXERCISES
CONVALESCENT PHASE
CONTRACTURES/DEFORMITIES
Cupping of Palm
CONTRACTURES/DEFORMITIES
Fifth Digit Flexion Contracture
CONTRACTURES/DEFORMITIES
Tight thumb-index web space
CONVALESCENT SPLINTING
Static Splints
No moveable parts,
and maintains a
position
Cupping of palm (CD)
Fifth digit flexion
contracture (H)
Tight thumb-index web
space (I)
CONVALESCENT SPLINTING
Dynamic Splint
Moveable parts that
allow joint movements
Low load, prolonged
stress that can be
adjusted to patient
tolerance
DYNAMIC SPLINTING
“ Dynamic splints offer greater potential for
correcting a developing contracture and the early
return of active function in areas of extensive burn
and grafting”
Richard RL, et al: Multimodal versus progressive treatment techniques to correct burn scar
contractures”. J Burn Care Rehabil 21:506, 2000
SCAR
Hypertophic scar
Keloids
SCAR MANAGEMENT
PRESSURE GARMENTS OR DRESSING
Elastic bandages
Tubular support
Pantyhose
SCAR MANAGEMENT
PRESSURE GARMENTS OR DRESSINGS
Mechanism:
Thinning the dermis
Altering the biochemical
structure of scar tissue
Decreasing blood flow to
the area
Reorganizing collagen
bundle
Decrease tissue water
content
SCAR MANAGEMENT
PRESSURE GARMENTS OR DRESSING
23 hours a day (removed
for bathing) for as long
as 12-18 months
Scar maturation: pale,
flat, soft
PRESSURE GARMENTS OR DRESSING
“A pressure dressing exerting >25mmHg will decreae
vascularity, decrease mucopolysacharrides,
decrease collagen deposition, and significnatly
lesens edema”
1. Ward RS: Physical Rehabilitation. In Carrougher, GI (ed): Burn Care and Therapy. CV
Mosby, St. Louis, 1998, p 293
2. Leung, PC, and Ng, M: Pressre treatment for hypertrophic scars. Burns 6:224, 1980
PRESSURE GARMENTS OR DRESSING
“If wound healing takes longer than 10-14 days (as in
deep partial thickness burn) or is skin grafted,
pressure usually is indicated”
Deitch EA, et al: Hypertrophic burn scars: Analysis of variables J Trauma23:895, 1983
SCAR MANAGEMENT
MASSAGE
Assist with ROM
exercise by making
tissue more pliable
Deep friction massage,
5-10 minutes, three to
six times daily
MASSAGE
“ Although no study has validated the use of massage
for patients with burn injuries, in long term, skin
pliability and texture appear improved by the use of
massage”
Miles WK, et al: Remodeling of scar Tissue in the burned. In Hunter JMet al, (eds): Rehabilitation of
the Hand. CV Mosby, St. Louis 1984, p 81
DEEP PARTIAL THICKNESS
POSTOPERATIVE REHABILITATION
1-2 days Postop
Whirlpool therapy recommended utilizing war water and Chlorazene or
Hibicleans cleanser
Blister should left intact unless they interfere with ROM. If the blister is
broken the skin surrounding the area should be debrided
Utilizing sterile technique, apply Silvadene or Collagenase ointment such
as Santyl (knoll) to open wounds
Apply light dressing to involved area. Each digit should be applied to
allow range of motion. Dressing should be change twice daily. Remove
excess Silvadene and then reapply Silvadene again
DEEP PARTIAL THICKNESS
A safe position splint is fabricated to wear between exercise
and at night
Active and gentle PROM exercise are initiated 6-8 times a day
to all involved joints as tolerated
1-2 weeks Postop
As the wound heal, apply Silvadene or ointment to the open
wound areas only
Advance to scar massage with lotion once the entire wound is
completely healed
Continue active range of motion and passive range of motion
and encourage normal use of hand as much as possible
DEEP PARTIAL THICKNESS
The safe position splint should be gradually discontinued.
4 weeks Postop
Discontinue splint altogether by 4 weeks post burn is
recommended
When wound is completely healed, fabricate a pressure
garments to area of scar to flatten and remodel any significant
scarring. It may be necessary to wear the pressure dressing
while sleeping if it interferes with range of motion during the
day
Dorsal taping and/or dynamic splinting maybe initiated if
range of motion is limited
