BURN WORKSHOP:
SPLINT AND POSITIONING
NURULHUDA BINTI MOHAMAD
Occupational Therapist
HOSPITAL ENCHE’ BESAR HAJJAH KHALSOM, KLUANG
Introduction
Traditionally burn were classified as first, second or third degree
depending on whether the burn was superficial, partial thickness or
full thickness.
Fourth- degree burn involve underlying tissues such as muscle and
fascia
Since 2001, main classification system used throughout the world is:
a. Superficial
b. Superficial partial
c. Deep partial
d. Full thickness
(Shakespeare, 2001)
Healing Proses
TYPE CRITERIA HEALING PROSES EVIDENCE
Superficial Burn involve only the Painful, healing usually Bessey, 2007
(first degree) epidermis within 1 week without any
residual scarring
Superficial Involve only papillary Burn depth are expected Bessey, 2007
partial- dermis & epidermis to heal 1 to 2 weeks and
thickness should not result in visible
burn change to the skin beyond
6 months
Deep Involve epidermis & Take longer than 3 weeks Bessey, 2007
dermal dermis to reticular to heal and skin grafting is
Partial- dermis recommended to promote
thickness early wound closure &
burns reduce the degree of
residual scarring
Full- Involvement of the Skin grafting is essential Greenhalgh,
thickness whole thickness of the since there is little potential 2007
burn skin & possibly for spontaneous healing
subcutaneous tissues
Highlight Massage
If wound are considered partial or full thickness in depth on a flexor
surface of the body, the client is at significant risk of long term functional
impairment.
If burn heals spontaneously (without need skin grafting) with complete
skin coverage within 2 weeks, the skin not develop hypertrophic scar
(red, raised, rigid) or functional impairment but can result long term
pigment changes.
Healing take more than 3 weeks, hypertrophic scarring inevitably result
and can lead to functional Impairment.
(Greenhalgl, 2007)
SPLINT & POSITIONING
Splint and positioning important in burn rehab
because of to maintained are tissues in an elongated
state, prevention of contractures, compression
neuropathies and decubitus ulcers.
(Spires et al., 2007)
THE AIMS OF SPLINT FOR BURN
MANAGEMENT
To immobilize a skin graft after surgery – splint used post grafting to
allow the graft to take, normally 5 -7 day.
To protect vulnerable structure e.g. exposed tendon.
To prevent skin and tendon contracture.
To maintain the joint range/ ROM when patient in post operation,
intubated in ICU or young children.
To prevent long term deformity.
GENERAL PRINCIPLE
Application of splint consider the location of the injury and must be
applied to maximize the lengthening of the skin of the affected area.
Special considerations for difficult joints such as axilla, hips, neck,
palms, hands, knee, wrist and toes
Positioning Principle Diagram
SPLINT PROTOCOL
ACUTE PHASE
The time need for use of both pre- and post-surgical splinting depends
on factors such as the client’s age, the length of time since burn injury
and severity of the deformity.(Esselman et al. 2006)
Prolonged static splinting is required following skin grafting procedures,
but therapy should be started within 2 to 3 weeks with the splint
removed for each session.
Six weeks after the surgery, night splinting a recommended to be
continued for 1 or 2 years (Schwarz, 2007)
If full ROM is not maintained, a program of stretching is recommended.
RECONSTRUCTIVE PHASE
OT role in this phase is to monitor and modify exercises related to daily
task.
Splints also recommended to maintain functionality and focus on
rehabilitation program that emphasis on activities of daily
living.(Latenser and Kowal- Vern, 2002; Richard and staley, 1994)
Gentle, prolonged stretch to healing tissue at its longest tolerable
length for at least 6 to 8 hours per day is most effective (Chapman, 2007)
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PAEDIATRICS
Splint wearing is 24 hours during active scar management period.
Splint given if wound takes longer than 2 weeks to heal.
Splints a worn 24 hours and removed only for exercise and dressing
changes.
Splint will be worn at night for up to nine months and during the day
initially.
Day regime includes more periods with splints off e.g. two hours on,
two hours off. Splint regimes are balanced with activities during the
day e.g. meal time, bath time.
Splint are always on for a day sleep.
FACTORS TO CONSIDER WHEN
PRESCRIBING SPLINT
Area of the body injured
Size/ length /extent and type of injury
The functional goal being addressed
Patient cooperation
Splint must user-friendly (poor applied splints can cause nerve
injury, loss of skin grafts and worsening of a burn wound)
Avoids pressure over body prominence
Compatible with wound dressing and topical medications
(Spires et al. 2007)
SPLINT CARE
Continual checking and remoulding needs to be done to
ensure that the goals of splinting regime are being achieved.
Check for issues that will require possible adjustment of the
splint such as, changes in odema, breakdown, fragile skin,
changes in ROM and maceration.
Ensure appropriate hygiene and cleaning of splints and skin.
PRECAUTIONS
If patient is not fitting into the splint, splint will require
remoulding.
Although there is a degree of discomfort in wearing splints, the
targeted body parts should not need to be “forced” onto the
splint.
Do not modify splint unless consulting with the treating
therapist.
Extra padding needed if patient skin have skin redness or ulcer.
SPLINT WORKSHOP
WHAT TYPE SPLINT ARE
SUITABLE FOR :-
Area of Burn :
Burns injury on the dorsal
surface of the wrist
EXAMPLE 1
Type of splint : Functional
Splint
Position : Wrist in 10°,
MCP in 70, PIP and DIP
joint in full extension and
thumb abduction.
WHAT TYPE SPLINT ARE
SUITABLE FOR :-
Area of Burn :
Hand palmar surface burn
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EXAMPLE 2
Type of splint : Pan Splint
Position : Wrist in 30° extension , All finger joint
in full extension and abduction
(Maximum)
Length : Forearm until tip of finger
Splint Pattern
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Splint Regime
Adult:
Wear splint 24 hours after surgery until 6 week
After 6 week, wear 6 to 8 hour per day.
Or wear on night only for 1 to 2 year.
Paediatrics :
Wear splints 24 hours and removed only for exercise and dressing
changes (during active scar management period) – 9 month.
Day time: 2 hours on, 2 hours off and always on for a day sleep.
Night time: Wear all night.
Splint Care
Don’t put on the hot weather/ temperature.
Clean splint using wet towel if necessary.
Do not modify the splint unless consulting
with the treating therapist.
HOME PROGRAM
ACTIVITIES
HOME PROGRAM 1
Range of Motion
Active ROM is encourage as soon as possible.
Stretches need to be low repetitions but long in
duration to provided a sustained stretch.
Active –assisted ROM and passive ROM are
useful if patient not actively participate.
Suggested doing exercise as daily routine
HOME PROGRAM 2
Functional Retraining
Encourage independence with ADL,
used adaptive devices for early success
for the patient and wean off as soon as
possible.
If patient unable tolerance with pain,
combine breathing exercises with mobility
HOME PROGRAM 3
Strength
The principles of strength training after
burn injury are no different to strength
training following other injuries e.g.
musculoskeletal injuries.
Example exercise: Start from antigravity
functional exercise use own body
weight as resistance e.g. using theraband
or free weight use equipment (sand
bag, dumble)
HOME PROGRAM 4
Skin Care
Daily washing / showering and diligent cleaning any
wounds.
Moisturizing at least daily
Daily sun protection : clothing or using hats for prevent
(SPF- sun protection factor) 30+ until scar are mature.
HOME PROGRAM 5
Massage
Aims to soften and desensitize the skin, prevent
adhesion, decrease pruritus, and stretch the skin/
scarred tissue.
TECHNIQUE :
With firm pressure.
Massage in slow circular motion using a flat hand/
finger.
If very thick use a pinch and role technique.
Do until scar is mature.
HOME PROGRAM 6
Compression Garment
Aims to prevent from scar formation and soften the scar.
Example: Tubigrip, custom made, Pressure Garment,
Coban.
TECHNIQUE
Wear 23 hour per day except during showering/ bathing,
massage and moisturizing.
Garment need to be washed and rinsed daily.
Educate to the patient and career is essential PG need to be
re-tensioned/ replaced/ re-measured every 3 – 6 month.
For the peadiatrics patient, retensioning garments is not
advisable because of children development.
HOME PROGRAM 7
Silicone Products
Generally used to soften red, raised or thickened
scars.
TECHNIQUE:
Applied on clean dry skin.
Gradually increase hours of wearing depending on
skin tolerance. ( silicone is not to be worn for 24
hours per day).
Can cleaned under warm or cold water with hand
soap.
Thank You
OCCUPATIONAL THERAPY STAFF
2015
