Chapter 47 Comprehensive rehabilitation of the burn patient
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The physical rehabilitation of patients who have sustained a burn injury is a serious undertaking and requires, among other disciplines, the involvement of physical therapy, occupational therapy and exercise physiology, in order to produce the most functional and cosmetic outcomes. Recent advances in medicine have significantly contributed to increased patient survival rates necessitating faster, more comprehensive and prolonged burn rehabilitation. With severe burn injuries, as perhaps with any other order of trauma, there is an urgent need for immediate and aggressive initiation of patient-specific rehabilitation programs. The distribution and depth of the burn injury clearly predict the patterns of deformity and joint contractures and mandate the establishment of therapeutic goals and the initiation of treatment as soon as possible. As stated previously, the more extensive the burn injury, the greater the rehabilitation challenge becomes. A seriously burned extremity in an otherwise modestly burned patient is much easier to restore to function than an extremity similarly burned in a patient with full-thickness burns involving multiple anatomical surfaces. In the case of seriously burned patients, the immediate and primary focus will always be preservation of life and wound coverage. Nowadays, burn rehabilitation specialists intervene early on in the patient recovery process through the development and implementation of rehabilitation programs intended to maximize the potential of functional and cosmetic patient recovery.
The primary short-term rehabilitation goal is to preserve the patient’s range of motion and functional ability. Long-term rehabilitation goals include the return of the patient to independent living and to train patients on how to compensate for any functional loss suffered as a result of the burn injury and contribute toward acceptable cosmetic outcomes.
This chapter addresses the evaluation, positioning, splinting/orthotics, casting, skeletal suspension, prosthetics, scar management, exercise, performance of activities of daily living (ADL) and patient and caregiver education utilized in burn rehabilitation along the continuum of care.
Evaluation of the burn patient
Upon admission to the burn center, patients undergo a comprehensive evaluation by burn rehabilitation therapists (physical or occupational therapists) in order to assess their medical status and formulate a plan of care. It is crucial that therapists document the findings of their evaluation in the patients’ medical record as they will serve as the baseline upon which progress will be determined. A good burn evaluation should include: (1) the history of how the accident occurred; (2) an interview with the patients’ caregiver in order to gather information regarding the patients’ pre-injury functional status and activity level; (3) documentation of the etiology, classification and total body surface area (TBSA) of the burn injury; (4) documentation of associated injuries such as fractures, smoke inhalation injury, exposed tendons and bone; (5) measurement of edema, range of motion (ROM), strength and sensation if appropriate; (6) assessment of activities of daily living (ADLs) performance; (7) development of short- and long-term treatment goals and (8) development and documentation of a treatment plan. The patients’ status should be reassessed on a regular basis and after each surgical procedure in order to update the plan of care as needed. Therapists should communicate the results of their evaluation and the treatment plan to the burn team, to the patients and their families.
Positioning and splinting of the burn patient
Positioning of the burned patient is vital in bringing about the best functional outcomes in burn rehabilitation. Positioning programs should begin immediately upon admission to the burn center and continue throughout the rehabilitative process. The role of the burn therapist is invaluable in designing a positioning program, which counteracts all contractile forces without compromising function. In planning and implementing an effective patient-specific positioning program, the therapist should be aware of the patient’s total body surface area (TBSA) of burns, the depth of all injuries, respiratory status and associated injuries such as exposed tendons/joints or fractures. Individualized positioning programs are monitored closely for any necessary adjustments depending on the patient’s medical status. The quote that ‘the position of comfort is the position of deformity’ applies to every burned patient who sustained a serious injury.
Anti-deformity positioning can be achieved through multiple means: splinting, mechanical traction, cut-out foam troughs and mattresses, pillows, strapping mechanisms, serial casting and in some cases, through surgical application of pins. The burn therapist needs to be aware of physician-specific protocols and work closely with the entire burn team to design the most effective positioning program. Orthotics and splinting devices are vital in burn rehabilitation as they are utilized extensively to obtain appropriate positioning of the entire body and to counteract the contractile forces that lead to deformity. No matter how the burn therapist approaches splinting (material choice, design, and application schedules) the goal is to achieve the best functional outcome at the completion of rehabilitation. When fabricating a splint or an orthosis the burn therapist must be aware of the anatomy and kinesiology of the body surface to be splinted. Also, the therapist should be well aware of all mechanical principles of splinting as they relate to pressure, mechanical advantage, torque, rotational forces, first-class levers, friction, reciprocal parallel forces and material strength.1
Positioning and splinting must be designed in a way to:
• Support, protect and immobilize joints
• Maintain and/or increase range of motion
• Remodel joint and tendon adhesions
• Protect newly operated sites (grafts/flaps)
• Stabilize and/or position one or more joints, enabling other joints to function correctly
• Assist weak muscles to counteract the effects of gravity and assist in functional activity
• Strengthen weak muscles by exercising against springs or rubber bands.1
• Be designed with function in mind
• Be lightweight and low profile
• Be constructed out of appropriate materials
• Allow for ventilation in preventing skin/wound maceration.1
Typical burn care positioning protocols describe the supine position in great detail. More emphasis is now being placed on the use of side-lying and prone positioning for patients with large burns who must be immobilized for extended periods of time due to newer grafting techniques that cover larger areas with fragile skin substitutes. When designing a positioning program the traditional joint angles are maintained, and the supporting surfaces are modified to maximize surface area while protecting bony prominences.
Side-lying may be used on a rotating basis for patients at risk for sacral or scapular skin breakdown. In a preventive program, the rotation is right side to supine to left side. The order is then reversed on a 1- to 2-h schedule. Full side-lying at 90° from supine should not be allowed for any significant length of time due to excessive pressure over the greater trochanter. A more appropriate position for side-lying is approximately 30–40° from the supine position, which distributes pressure more evenly between the head of the femur and the lateral portion of the sacrum.
The mechanics of a side-lying position can be accomplished using pillows or wedges made of foam or wood. The advantage of foam or wooden wedges is that they can be placed directly under the mattress with less manipulation of the patient. As the rotation schedule is completed the wedge can either be removed for the supine position or transferred to the opposite side of the mattress to achieve side-lying on the opposite surface.
Prone positioning systems are usually the position of last resort (Fig. 47.1). They are reserved for patients who are not successfully being managed in supine or side-lying. There may be non-healing grafts or wounds in the rectal region that increase the risk of sepsis due to the introduction of fecal matter. Other common candidates for this protocol include those with sacral pressure ulcers or posterior trunk grafts that are not healing.
There are a host of issues that must be considered when instituting a prone program. Airway is always the first issue that must be considered when designing a prone positioning mattress. The supporting surface is cut from a solid open-cell foam mattress that is placed on a wire mesh bed frame. Airway concerns are addressed first and the patient is evaluated for mode of respiration. Nasal and tracheal intubation are issues to consider, but are not contraindications for the prone position. A trough should be provided so that direct access can be obtained for routine airway care and if breaths are needed using an Ambu-bag. If the airway becomes compromised the prone position should be abandoned immediately until proper respiration is established.
The facial opening should be cut in a manner that maximizes weight distribution without allowing the head to enter into the opening. Using this protocol places direct weight-bearing pressure on the brow ridge, zygomatic arches, and the anterior mandible. These structures should be monitored closely and the patient should be educated that breakdown is likely to occur due to the limited subcutaneous tissue protecting the face. If burn scars are encroaching on the eyelids, then the corneas should be evaluated as well. Corneal abrasion can be avoided with due diligence and prevention of the foam from contacting the unprotected eye. Countersinking a gel cushion into the upper portion of the foam mattress can protect the forehead and brow-ridge.
The sternum, pelvic region, and patellae are protected with the use of an air-cell mattress that is inserted into the mattress in a length-wise manner. The air-cell segments are typically supplied in standard lengths and may not reach from the sternum to the ankles. If there is an unsupported area between the distal portion of the air-cell mattress and the dorsum of the foot, then the area can be supported with open cell egg-crate type foam. The feet are supported at the distal end of the mattress with a foam footboard. Extra precautions should be taken to evaluate the elevation of the great toe from the supporting bed frame.
In the prone position, all of the traditional joint alignment suggestions are maintained with the possible exception of the elbows. Shoulder mobility dictates the style of mattress that can be made for the individual burn patient. If the patient has >115° of abduction, then the mattress is modified to horizontally adduct and externally rotate the shoulder while flexing the elbow to allow for elevation of the hands. This minimizes edema in the hands and allows for greater function once the prone position is no longer needed. If the shoulders have limited abduction then a ‘butterfly’ cut is used to allow for horizontal adduction of the shoulder to protect the brachial plexus with the hands remaining slightly dependent. This will result in some hand edema, which can be addressed with pressure wrapping (Coban™ glove) and active exercise.
Acutely, in aiding with facial edema reduction, the head should be positioned by placing in midline and elevating the head of the bed at 30–45° if the patient’s hips are not involved. In cases where the hips are burned, the entire bed may be elevated at the head of the bed with the use of shock blocks (wooden blocks 12–16 inches high with recessed slots for bed legs). This will avoid positioning the hips in the flexion contracture position (Fig. 47.2). In the cases where the ears are burned they may be protected by strapping ear cups made of thermoplastic materials or foam.2 An ear conformer may be constructed to prevent the rim of the ear from contracting toward the head. Internal ear canal splints may also be fabricated and serially adjusted as the circumference of the canal increases. In addition, if the ear is affected, a soft circular foam can be positioned posteriorly to the head to elevate the ears of the surface of the bed. A nasal obturator may be required to maintain the nostrils open. These obturators may be serially adjusted as the circumference of the nostril increases. Mouth splints are utilized for the prevention of oral microstomia. These devices are custom-made by the therapist or they may be obtained commercially. Mouth splints may be fabricated static or dynamic for the horizontal or vertical opening of the mouth.3–6 In cases of severe microstomia where compliance is an issue, an orthodontic commissure appliance which attaches to the teeth may be fabricated by an orthodontist.7 The use of stacked tongue blades is an acceptable technique to aid in reversing oral microstomia. Ongoing research looks at the development of a microstomia device that circumferentially opens the mouth according to its anatomy (Fig. 47.3). Facial scar hypertrophy may require fabricating a high thermoplastic transparent mask such as the Uvex™ and W-clear™ masks or a silicone elastomer facemask.8–10 A semi-rigid low thermoplastic opaque mask may also be fabricated depending on the state of scar maturation.
Figure 47.2 Wooden blocks are utilized to place the bed on an incline to help with edema reduction and prevent hip contractures.
The neck is positioned in neutral or in slight extension of approximately 15° without any rotation. The amount of neck extension must not be so great that traction on the chin causes the mouth to open. Positioning may be achieved with a short mattress supine, a rolled towel or foam cushion placed behind the upper back on the scapular line. Pillows should be avoided in the cases of anterior neck burns as they may lead to flexion contractures. In the case of anterior neck burns a conforming custom thermoplastic collar may be fabricated (Fig. 47.4).11 For long-term needs, a soft neck collar or a Watusi-type collar may also be fabricated as the patient’s wounds heal and contractures or scars develop. The Watusi-type collar allows for isolated, direct pressure to a thicker scar band.10,12,13 It has been observed that in some cases, acute patients rotate or laterally flex their neck on one side, which may lead to a lateral neck contracture (torticollis). If the patient is to remain in bed for a while, a dynamic head strap mechanism may be fabricated to counteract the lateral neck contractile forces and bring the neck in the neutral position. For the prevention of torticollis the therapist may fabricate a lateral neck splint which conforms to the head of the patient, the lateral neck and anterior/posterior shoulder (Fig. 47.5).
Contracture resulting from unilateral or asymmetric burns of the neck, axilla, trunk and groin will cause lateral curvature of the spine (scoliosis). The level and amplitude of curvature will vary with the site and severity of the contracture. In addition, pelvic obliquity accompanying asymmetric hip or knee flexion contracture will impose a lateral lumbar curve. As long as the patient is recumbent, lateral curvature can be prevented by maintaining straight alignment of the trunk and neck (Fig. 47.6). However, the curve is often insidious in onset and will not be recognized until the patient begins to walk. Trunk list observed early in the ambulation period can be simply a transient accommodation to pain and wound tightness, but a persistent list may herald the development of scoliosis. Other subtle signs of spinal curvature are asymmetry of shoulder levels, scapular asymmetry, asymmetry of dependent upper extremity alignment to the trunk and asymmetry of pelvic rim levels. A spinal mobilization exercise program is established with a patient once a curvature is identified, however once there is an established asymmetric contracture it is difficult by therapeutic means to stretch it out, so it is probably better to deal surgically with a deforming scar early than to permit even minor scoliosis to persist.
Acutely, the upper extremity positioning program focuses on reducing edema through elevation. Failure to reduce edema in the first 48–72 h can promote the development of a fixed deformity. Additionally, improper elevation techniques for the upper extremity may lead to soft tissue calcification, increased bone density, and compressive neuropathies. The recommended position for the burned shoulder and axillary complex is 90° abduction, 15–20° horizontal adduction and external rotation towards maximal. Abduction alone places the glenohumeral joint at risk for anterior subluxation if the position is maintained for an extended period of time. Placement in horizontal adduction anatomically reduces the potential for tractioning of the brachial plexus or peripheral nerve compression. The glenohumeral joint is externally rotated in order to counteract anticipated deformities of internal rotation and adduction and to maintain balance of the soft tissues of the shoulder complex.
Positioning of the shoulder may be achieved with splints, silicone-filled pillows, bedside tables, foam arm troughs, metal abduction troughs, and thermoplastic slings suspended from a trapeze mechanism (Fig. 47.7). Splinting of the shoulder joint becomes more intensive as scar maturation heightens the risk of contracture development. Airplane splints are used for the resolution of axillary contractures and post-operatively to protect reconstructive procedures. To accommodate wound dressings and promote healing, a three-piece airplane splint may be fabricated (Fig. 47.8). Other adaptations may be required in the presence of amputations. Pre-fabricated airplane splints come equipped with mechanisms that allow for adjustments depending upon available shoulder range of motion.10,11,13 A figure-of-eight axillary wrap may be utilized in conjunction with an airplane splint to provide compression for axillary contour and elongation of skin surfaces (Fig. 47.9). For successful contracture management to the shoulder, the positioning program must be supplemented by exercise routines for range of motion and strengthening.
Figure 47.8 A three-piece airplane splint may be fabricated to accommodate wound dressings and promote healing while maintaining the shoulder abducted.
Acutely, elevation and extension is the desired position of the elbow. Severe burns involving the elbow may result in flexion contracture and threaten posterior exposure of the joint. Full extension is the protecting position for the elbow. If the joint is exposed posteriorly, extension may need to be rigidly maintained for several weeks. If the joint is not exposed, mobilization into increasing flexion range can begin very soon after the burn. The elbow is integral to the so-called delivery system for the hand, and elbow range to full or near-full flexion is more important for overall function than range to full or near-full extension.
Radial head rotation for pronation and supination is less often affected by the burn injury than flexion and extension. The pronators and supinators are frequently injured in electrical accidents where bone, being a poor conductor, heats destroying the muscles closest to it. Forearm rotation is essential for accurate hand placement and the rehabilitative program must seriously address that function. Depending on the location and severity of the injury the forearm may be positioned in neutral or in slight supination. Static elbow splints may be soft or custom-fabricated of thermoplastic materials. An anterior elbow conformer may be fabricated over the burn dressing. Dynamic elbow extension or flexion splints may be utilized to provide prolonged gentle sustained stretch and aid in the correction of contractures.14 Forearm dynamic pronation/supination splints may be custom-fabricated or obtained commercially for the correction of contractures.10,11,13
Treating therapists must have a thorough understanding of the effects of thermal injury on the anatomical structures of the wrist and hand. The presence of dorsal hand edema leads to intrinsic muscle ischemia and a resultant ‘intrinsic-minus’ posture. The unsupported burned hand postures in wrist flexion, metacarpophalangeal (MCP) hyperextension, interphalangeal (IP) flexion, thumb adduction, and thumb IP flexion. The overall appearance is that of a claw deformity (Fig. 47.10a) Edema following a full-thickness burn to the dorsal hand imposes MCP hyperextension and IP flexion (Fig. 47.10b). Persistence of this position results in a claw deformity). The claw hand posture is primarily due to post burn edema, but may persist throughout the course of treatment due to scar contracture. Among the digits, the second and fifth most easily drift into MCP hyperextension because each has a proper extensor tendon.
Figure 47.10 (a) Edema following a full-thickness burn of the dorsum of the hand – imposed metacarpophalangeal extension and interphalangeal flexion. (b) The deformity resulting from the persistence of this position is that of a claw hand.
While superficial burns result in minor, transient edema, full thickness injuries exhibit more severe and prolonged postburn edema. Superficial hand burns should not be splinted in order to allow for frequent movement and the freedom to function independently. In cases of severe thermal injury it is important to monitor for signs and symptoms of vascular insufficiency or compartment syndrome. In treating the edematous, burned hand, it is important to position the hand above the level of the heart at all times, without compromising the neurovascular supply to the hand.10,11,13
Acute positioning of the wrist and hand after burn injury is for edema control, immobilization/protection of tendons, joint structures, and/or skin grafts, and optimal positioning to maintain soft tissue lengths and functional abilities. Within the first 24–72 h it is recommended that the wrist be splinted into extension, allowing the MCP joints of digits 1 through 5 to fall into flexion due to the normal tenodesis action of the wrist and hand. Wrist extension is essential in order to control digital position and prevention of a claw hand deformity. The recommended functional position of the wrist is from 0–30° of extension.
The burned wrist and hand should be positioned to oppose impending wound contracture. The optimal position for the burned hand is wrist 0–30° extension, 70–80° MCP flexion and IP joints in full extension (although some burn centers may advocate a slight amount of IP flexion deeming the position to be ‘safe.’). The thumb should be positioned in a combination of palmar and radial abduction with the MCP/IP joints slightly flexed. This position resembles the ‘intrinsic-plus’ position and is achieved through fabrication/fitting of a burn hand splint by a rehabilitation therapist (Fig. 47.11; The burn hand splint positions the hand appropriately to minimize soft tissue contractures and preserve functional mobility). Involvement of the extensor tendon apparatus should be assumed and protected until viability of the system is known.15 Continuous splinting is recommended to manage edema, exposed tendons, peripheral neuropathies, and uncooperative/unresponsive patients.
Figure 47.11 The intrinsic plus position hand splint (burn hand splint) positions the hand appropriately to prevent contractures and preserve function.
In the intermediate phase, positioning and splinting is used to prevent/correct deformities and protection of surgical reconstructed sites. Splints may be fabricated dorsal, volar or on the medial/lateral aspects. Contractures are a major complication of hand burns as they affect one’s ability to perform activities of daily living. Dorsal hand burns are prone to contract into MCP hyperextension, IP flexion, and thumb adduction and should be splinted into MCP flexion, IP extension, and thumb palmar abduction. The most common post-burn upper extremity contractures are: wrist flexion, index finger MCP hyperextension, index finger proximal IP flexion, and small finger MCP hyperextension/proximal IP flexion.16 The claw hand deformity is functionally detrimental because it makes it impossible to smoothly reach around objects (Fig. 47.12).
Burns to the volar surface of the forearm will predispose the patient to wrist flexion contracture, while burns to the dorsal surface will likely result in a wrist extension contracture. If the wrist ROM becomes limited in a specific direction, splinting the wrist in the opposite direction is indicated. The fifth digit is occasionally pulled into extreme abduction and hyperextension by scar contracture, muscle imbalance, or ulnar neuropathy. The thumb may become similarly displaced into adduction and retroposition. It is important to remember that the likelihood for MCP joint problems exists throughout scar maturation. Palmar hand burns are prone to MCP flexion and thumb opposition contractures and should be splinted into palmar extension and thumb radial abduction.
Static positioning with custom thermoplastic splints can be relatively efficient. However, two common faults are seen in custom splints that are designed to gain MCP flexion and to position the thumb in MCP flexion/radial abduction. If the distal transverse fold of the splint is not proximal to the MCPs of digits 2–5, the splint will impede rather than favor MCP flexion. If the thumb component of the splint applies volar pressure rather than medial pressure, the MCP will extend and the first metacarpal will become correspondingly more adducted. The first MCP joint should be maintained in slight flexion and pressure from the splint should be applied just to the medial surface. Any degree of first metacarpal adduction contracture increases the likelihood that the proximal phalanx will be pushed into hyperextension and eventually into subluxation.
In the case of circumferential hand burns, a palmar extension splint is fabricated to prevent flexion contractures and a cupping deformity of the palm (Fig. 47.13). The burn hand splint and an extension splint may be alternated. A ‘sandwich’ splint may be fabricated which includes a burn hand splint with a dorsal shell over the IP joints to prevent flexion of the digits. All splints may be secured with elastic bandage or with Velcro® strapping components (Fig. 47.14).17 Individual gutter splints are used to prevent flexion contractures, to restrict boutonnière and mallet finger deformities, and for protection of exposed extensor tendons until wound closure C-bar splints are used to prevent adduction contracture of the first web space. Figure-of-eight splints are fit to correct or restrict swan neck deformities.
Dynamic splints are utilized to provide low-load prolonged stretch to counteract contractile forces. Dynamic splinting of the hand will focus on MCP extension/flexion splints, IP flexion/extension splints, thumb abduction, and may include pre-fabricated or spring-loaded splints (Fig. 47.15). Patients may require dynamic splinting to assist muscles weakened by peripheral neuropathy. The therapist monitors dynamic splinting closely and makes frequent adjustments in order to provide effective tissue mobilization. Additionally, the fit of dynamic splints is checked frequently to insure that the anatomical structures remain properly aligned.
When anterior burns extend from the abdomen to the thigh, hip flexion is the position of comfort. If the hip is fixed in any degree of flexion, posture will be modified. Bilateral symmetric contractures impose increased lumbar lordosis or knee flexion or both. Asymmetric contracture will cause pelvic obliquity and scoliosis. In adults and older children thighs are more likely to be held in adduction than in abduction, whereas in pre-ambulatory infants the secondary component of the contracture is abduction. Thus, for the hips the preventive position is full extension, 0° rotation and symmetric abduction of 15–20°. If elevation of the upper body is needed for edema reduction then the entire frame of the bed is elevated with the use of wooden shock blocks placed at the head of the bed. Soft mattresses should be avoided as they may promote hip flexion. Hip positioning is accomplished with the use of abduction pillows and other strapping mechanisms eliminating hip rotation. If the patient wears bilateral foot splints then connector bars may be utilized on the splints to bring about the desired bilateral hip positioning stated above. Hip flexion contractures may be serially corrected with an anterior hip spica or with a 3-point hip extension splint (Fig. 47.16).10,11,13 Subtle hip flexion contractures can be easily overlooked when the patient stands, there being only a slight increase in lumbar lordosis or forward or lateral shift of the trunk. If established hip flexion contractures are not surgically corrected, body posture is likely to be permanently altered with scoliosis or exaggerated lordosis.
Burn injury to the anterior or posterior surface of the lower extremity that crosses over the knee joint may result in knee flexion. Deep anterior burns may expose the joint, occasionally destroying the patellar tendon. Deep posterior burns result in bridging scar formation. The appropriate position for the knee is full extension to be maintained by splint or in severe cases skeletal traction until there is efficient quadriceps function and the patient is ambulatory. Thereafter, night splints must be used until scar contracture is no longer a threat. Knee splints may include a posterior custom-made thermoplastic knee conformer or a soft knee immobilizer.
Persisting bilateral knee flexion contractures will impose hip flexion. Persisting unilateral contractures may impose pelvic obliquity and scoliosis. As with the hip, posture alteration may be so subtle as to be overlooked. Correction of even a slight contracture should be a surgical priority as should elimination of a soft bridging scar band that does not prevent complete willful knee extension but causes the patient habitually to hold the knee in slight flexion.
Ankle equinus is the most frequently occurring deformity involving the foot. Initially, it is related more to gravity and failure to support the foot at neutral at the talotibial joint than to the early effect of the burn. Loss of deep and superficial peroneal nerve function will compound the problem by encouraging the foot to drift into inversion as well as equinus because of loss of dorsiflexion and eversion motors. In the end, the total deformity for the unsupported foot may be ankle equinus, hind-foot inversion, and forefoot varus and equinus. Ankle equinus quickly becomes a resistant deformity so that within a few days or even hours the foot can no longer be positioned at 90° of dorsiflexion in the neutral ankle position. Eventually the contractures of scar, muscle and capsular structures combine to fix the deformity.
Equinus deformity and the attending inversion and forefoot varus can be prevented by accurate and unyielding support of the foot in neutral alignment or slight dorsiflexion. If the patient must be nursed prone, the feet must be allowed to fall free from the mattress. Static splinting if not performed correctly by an experienced therapist is often unsuccessful because of the patient’s desire and tendency to plantarflex strongly, displacing the splint and leading to ulcers of the heel, malleoli, toes and where the splint edges touch the skin. A stable footboard may be effective if the feet are kept securely and totally against it. For large burns and particularly for circumferential burns of the lower extremities, skeletal suspension incorporating calcaneal traction will support the foot at neutral if the traction pin is placed in the calcaneus well behind the axis of ankle motion. A balanced traction system demands that the knees be supported in flexion with tibial pins at the level of the tibial tubercle. Calcaneal pins will not prevent forefoot equinus. If traction must be employed for several weeks, proximal pull dorsal pins in the first or first and second metatarsals may be required for support of the forefoot. Transmetatarsal pins are useful as well when calcaneal traction alone is not sufficient to correct equinus.
Minor established equinus deformity can be corrected with a standing and walking program. At the outset graduated heel lifts may be used to accommodate to the deformity. If the patient must be bed-confined, skeletal traction through the calcaneus may be the quickest and most efficient way to correct the deformity. Traction is effective even if scar contracture contributes to the deformity. Serial corrective casts or posterior splints alone are useful mainly for minor contractures. For the treatment of circumferential foot/ankle burns anterior foot splints are also fabricated and their application is alternated with the posterior foot splints in preventing plantar or dorsal foot contractures.10,11,13 The Multi Podus® System foot splints may be utilized for the positioning of the burn foot/ankle as they relieve heel pressure in preventing pressure ulcers (Fig. 47.17). For fixed, unyielding deformity, scar release combined with tendo-Achillis lengthening with or without posterior capsulotomy is a standard surgical procedure that yields inconsistent results. The correction achieved is often just to neutral or to slight dorsiflexion. The Ilizarov technique has been used with generally satisfactory immediate results in severe cases.18 No matter how correction is achieved, if there are no dorsiflexion motors and if the range of ankle motion is only a few degrees, ankle fusion may in the end yield the best functional result.
Figure 47.17 The Multi Podus splint is utilized to position the burned feet appropriately and prevent heel and malleoli skin breakdown.
The most common intrinsic deformity of the foot is extreme extension of the toes due to dorsal scar contracture. This deformity is insidious in onset and is difficult to prevent as there is no type of non-skeletal splinting that will hold the toes flexed. In its extreme, the deformity includes dorsal metatarsophalangeal (MTP) subluxation which may involve one or all toes depending on the location of the scar. The metatarsal heads become prominent on the plantar surface and walking may be painful. Correction of the deformity requires dorsal surgical release of the contracture, manual correction of the deformity and in severe cases intrinsic or extrinsic pinning of the digit or digits in an overcorrected position, i.e. MTP and interphalangeal flexion. The deformity will commonly if not inevitably recur to some degree, unless the patient, after the operation, is able to achieve in all digits active MTP flexion.
Dorsal scar contractures extending from leg to foot to toes may pull the foot into marked inversion if the scar is medial or into eversion if the scar is lateral. The fifth and first toes may be separately displaced by the same scar bands. These contractures must always be surgically corrected. Their persistence will lead to bone deformity in a growing child and will permanently adversely affect foot and ankle function. Even slight inversion, whether imposed by scar contracture or motor weakness, will increase pressure on the lateral border of the foot, leading to callus formation and a painful inefficient gait. Occasionally, the base of the fifth metatarsal is so offensive as to require partial surgical osteotomy.
When there is both anterior and posterior scar contracture, the talus will remain aligned with the calcaneus in a relatively plantar flexed position as the midfoot and forefoot are pulled into dorsiflexion. The result is so-called rocker bottom foot with the head of the talus being the principal weight-bearing feature. This deformity once established defies correction by usual surgical means because of the shortage of soft tissue and because vessels and nerves cannot be stretched to accommodate to the corrected position. The Ilizarov technique may offer a partial solution to the problem. Removal of the head of the talus may give a reasonable weight-bearing surface. With chronic painful ulceration, amputation is the best treatment.18
Orthotic treatment of the lower extremity
The approach of the orthotist in treating the injured foot depends on the extent of the burn injury. Orthotic shoes, which are the fundamental component of most lower extremity orthotics, may be utilized with some modifications in correcting deformities of the burned foot. Modifications of these shoes may include arch pads, molded foot thermoplastics, tongue pads, and metatarsal bars. The orthotic shoes should distribute all forces to the foot appropriately and should reduce pressure on sensitive or deformed structures and encourage total surface weight-bearing along the plantar aspect of the foot. Inserts for plantar foot support such as the University of California Biomechanical Laboratory (UCBL) type may be utilized as indicated.
During the preambulation stage the patient may be fitted with those orthoses; if properly utilized, they can position the ankle joint appropriately, and assist in preventing or correcting plantar/dorsal contractures and inversion/eversion of the foot.
Leg length discrepancies are seen frequently in the cases of severe lower extremity burn injuries and they should be addressed with a shoe lift. The ankle–foot complex is difficult to address, especially in the case of a severe thermal injury. In most cases, the resultant deformity is the equinovarus foot. Both conventional and thermoplastic systems may be designed to treat the equinovarus or equinovalgus foot. Such systems may include a metal ankle–foot orthosis (AFO), polypropylene plastic posterior AFO (solid ankle or with an articulation), an AFO with stirrup attachment, an AFO with stirrups and patellar tendon support. A dorsiflexion spring assist may be incorporated in the AFO to aid weak ankle motion. Different straps such as a valgus correction strap may be attached to the AFO for the correction of specific problems. Interface materials, such as silicone, Plastizote® and Aliplast®, can be incorporated into an AFO to provide protection of the soft tissue, provide for total surface weight-bearing, and to accommodate any anatomical anomalies that may be present (Fig. 47.18). In the event that a return of range of motion is anticipated, an AFO could be fabricated that can be modified as the patient progresses. The ankle joints can be incorporated into the AFO, however, left solid and articulated at a later date.
Figure 47.18 Specialized materials may be required to accommodate anatomical anomalies that may be present. Standard ankle–foot orthoses can be fabricated utilizing silicone materials to accommodate excessive scarring and limb loss.
During more complicated cases, and depending on the anatomy and function of the lower extremities, a knee–ankle–foot orthosis, hip–knee–ankle–foot orthosis or a trunk–knee–ankle–foot orthosis may also be designed for the best functional outcome.19
Casting has been used in patients with burns for postoperative immobilization to promote graft adherence and to minimize scar contracture during the remodeling phase of healing.20 Circumferential casting after skin grafting to the lower extremity is an effective means of providing protection to the grafted area.21 Serial casting has been used successfully on outpatients with burns when active range of motion is limited due to scar tissue formation.22 The goal of serial casting is gradual realignment of the collagen in a parallel and lengthened state by constant circumferential pressure.23 Prolonged gentle sustained stretch provided by the cast aids in tissue elongation for the correction of contractures (Fig. 47.19). Burn scar under constant traction shows collagen formation in parallel alignment along the forces of stress.24 Low intensity force with prolonged duration for stretching can be applied to connective tissue whether it is scarred, contracted or surgically shortened.25 Casting is a relatively simple, fast and painless intervention and provides an alternative to dynamic splinting but is not feasible when patient compliance is an issue (e.g. pediatrics).
Figure 47.19 Serial casting provides prolonged gentle sustained stretch and aids in tissue elongation and correction of contractures without pain.
A pre-casting assessment should include the following: ROM measurements, end-feel assessment of the involved joint, duration of limitation, skin or wound status, neurovascular status, functional needs, and cognition of all involved parties. The patient is educated on the position in which the cast will be applied, the expected duration of casting and any restricted activities. Ridgway (1991) described the serial casting technique: (1) skin hygiene; (2) scar massage with moisturizer; (3) ROM exercises and assessment; (4) wound dressings; (5) application of a silicone insert; 6) extremity in figure-of-eight wrap or tubular bandage; (7) padding over bony prominences; (8) one therapist to position and one therapist to fabricate cast. Serial casting may be supplemented with splinting of adjacent joints. There should be a minimal time lapse between cast removal and reapplication.
Patients may require premedication and may also benefit from soft tissue preconditioning (heating) for stretch prior to cast application. Precautions should be taken to ensure proper and evenly applied padding, including extra layers at the proximal and distal ends of the cast. The casting material should be rolled out and handled with an open hand as much as possible. Aggressive molding or over tight applications are to be avoided and can lead to compression neuropathies or vascular compromise. When cast materials harden an exothermic reaction occurs, causing the temperature within and beneath the cast material to rise, which leads to elevated temperatures and burns. The greatest risk of thermal injury occurs when a thick cast using warm dip water is allowed to mature while resting on a pillow.26 A variety of materials are available for the fabrication of casts. The most widely known would probably be Plaster-of-Paris. Plaster is fast setting when reacting with lukewarm water. Plaster casts are inexpensive, stronger, and easy to fabricate. However, they require longer drying times (24–48 h), are prone to indentations and skin irritations, and are heavier. Other disadvantages of this technique include a decreased water resistance and breakage if not constructed strongly enough. Plaster casts may be removed with a cast saw or moistened and removed with scissors.
Fiberglass casting material is an alternative to Plaster-of-Paris. Fiberglass casting tape is fast setting when reacting with cool water. Fiberglass materials require a shorter drying time (15–30 min), are lighter weight and more durable, and offer resistance to dirt and water. Fiberglass casting methods are more costly than plaster. Because of fiberglass’s abrasive properties, therapists must wear gloves for handling the materials during cast fabrication and removal. The patient’s skin and clothing should be protected from contact with the fiberglass casting tape, as well as to fiberglass fibers during cast removal. Fiberglass casts require use of the cast saw for removal.
Recently, non-latex polyester materials such as Delta-Cast™ are utilized as alternatives to plaster and fiberglass. These materials, which resemble fiberglass, are very lightweight, flexible, and because of their elastic properties conform very well. These casts may be cut in a bivalve fashion so that they can be removed and reapplied after wound care, hygiene, and exercise.27
After cast fabrication is complete, the clinician should check the following: firmness of the cast, neurovascular status of the extremity, sharpness of cast edges, and any signs of the cast rubbing adjacent structures. When casting is completed, the patient should feel a gentle, but not painful stretch. The first cast should be removed at approximately 24 h and thereafter, depending on the patient’s tolerance, it could be applied for up to 1 week at a time. In cases of casting over open wounds, the cast should be removed every 1–2 days in order to avoid complications in wound healing.21,23 The use of insert material for scar management under casts has been documented and found to be useful.23 Serial casting is terminated when either normal range of motion has been restored or no further functional gains are achieved.
Skeletal suspension and traction
Skeletal suspension and traction systems have been used to a limited extent in burn management for a number of years. The early reports of Larson28 and Evans29–31 described the use of skeletal suspension for positioning and for extremity elevation for open wound management and of skeletal traction for prevention and correction of contractures. The later reports of Harnar32 and Youel33 deal mainly with the management of hand burns with the skeletally anchored digital traction splints bearing the names banjo, halo, and hay rake (Fig. 47.20).
The adaptation of skeletal suspension and traction systems to burn management grew out of earlier experience with traction to correct the elbow and knee contractures of patients with rheumatoid disease, and out of traction and suspension as definitive means for treating certain extremity fractures. In its earliest application to burn management, skeletal suspension was used for extremity elevation only to facilitate wound care. From this experience evolved better-defined traction systems, including those expressly designed for hands and feet. Rehabilitation therapists may remove the patient from the traction apparatus as indicated for exercises and ambulation and reapply the traction at the completion of treatment. Positioning within the traction is often changed by nurses and therapists by altering the amount of the traction weights, thus preventing the affected joints from being locked into one position over time (Fig. 47.21).
Figure 47.21 Skeletal traction is utilized for positioning of extensive burns and for the protection of delicate grafts through suspension. Rehabilitation therapists may remove the traction and ambulate or exercise patients as needed. Traction weights may be changed to achieve different positions within the traction system and help shift the weight of patients in bed.
A prosthesis is a device used to replicate the function and appearance of a missing limb. Amputations among the burn patient population most often occur as a result of electrical insults, but can also result from more severe thermal injuries as well. Prosthetics are designed, fabricated, and fit by a certified prosthetist. Each device is individualized based upon the needs of the patient. But, in general, the prosthesis should be comfortable to wear, easy to don/doff, lightweight, of durable construction, and be cosmetically appealing. The prosthetist and rehabilitation professional will consider the following when designing the prosthesis and its components: level of amputation, shape and contour of the residual limb, functional expectations, cognitive abilities, vocational requirements, hobbies/leisure pursuits, and financial resources. Standard prosthetic texts are useful in providing broad basic information and explanation of the many components available and their use.34,35
Patients who have sustained severe burns and subsequent amputations have complex, long-term impairments and face considerable functional deficits.
Severely burned patients tend to have sensorimotor limitations in the intact extremities, which may affect their ability to utilize a prosthesis. Their limitations and strengths are important considerations when planning treatment. These patients may exhibit muscle weakness not usually seen at the same amputation levels in the non-burn patient. Areas of weakness should be noted and compensation such as increasing joint stability through alignment or componentry should be provided. Burned individuals may use their remaining functioning extremities differently than patients without total body involvement. Prosthetic rehabilitation should enhance adaptations and necessary compensatory methods. The challenge to the prosthetist is to design a device which is maximally useful to a person who may have multiple limitations. To be useful, a device must be as easy to use as possible. Simplicity often determines whether the device is successful or discarded.
Prostheses may be preparatory or definitive. Preparatory devices are ones fitted while the residual limb is still maturing. A preparatory prosthesis is provided when reduction of stump volume is anticipated or when fitting over a bulky dressing is necessary. These devices are usually simple, passive devices that allow for early motion skills and weight-bearing through the affected limb. Some patients will continue to use their preparatory prosthesis for extended periods of time while other areas of the body are treated. Prior to definitive fitting, body weight, residual limb volume, wear and use patterns should be stable in order to optimize the long-term result with the definitive prosthesis. The definitive prosthesis is fit when the residual limb is fully mature. The use of a preparatory prosthesis is not mandatory, but the use of one will improve the fit and control of the definitive prosthesis; and may, secondarily, reduce the amount of time needed for rehabilitation post-burn injury.
Prosthetic preparation in burn rehabilitation begins in the post-surgical phase. Early prosthetic treatment of an amputee includes splinting for the prevention of contracture. An upper extremity splint may extend past the distal end of the residual limb to match the length of the whole limb, thus assisting a patient in retaining the concept of length. Initially, therapists must address: promotion of wound healing; pain management; residual limb shaping; prevention of contractures; skin desensitization techniques (tapping, massage, scar mobilization, pressure application); edema control, and coping mechanisms for adjustment and grief. With early socket fitting, some skin problems will be encountered, but these are not usually of major significance. Silicone gel or urethane socket inserts have been used successfully for pressure relief to burn-scarred skin. As wound healing progresses, prosthetic training will begin to focus on care of the prosthetic device, don/doff methods, skin inspection routines, weight-bearing with the device, and progressive functional skills.
Just as upper extremities are different from lower extremities; so, too are upper and lower extremity prostheses. The minimum requirements for successful use of an upper extremity prosthesis are: trunk control to support an upright posture, sufficient upper body strength to selectively activate the control devices, and static and dynamic balance skills. The patient will need to be trained on specific body movements to develop control of the upper extremity prosthesis. Glenohumeral flexion provides excellent power and reach for functional routines. It can be used to flex the elbow, activate the terminal device, and for activities away from the midline of the body. Scapular protraction is also trained for activation of the terminal device and facilitation of fine motor tasks at midline or close to the body. The other motions of glenohumeral depression/elevation, extension, and abduction are most frequently used to lock or unlock an elbow joint.
Different types of upper extremity prostheses are available along a continuum from mostly passive or cosmetic to primarily functional. Most devices fall somewhere in the middle range between cosmesis and function. Cosmetic prostheses are difficult to keep clean, expensive, and ultimately sacrifice function for appearance. Functional prostheses fall into two categories. They can be designed to be body-powered (using cables) or externally powered (myoelectric or switch control). Body-powered prostheses are moderate in cost and weight, more durable, and offer higher sensory feedback. However, they require more gross limb movement and can be less cosmetically appealing. Externally powered prosthetic devices allow for more proximal function, greater strength for grasp/prehension, and improved cosmesis. Additionally, they may be heavy and expensive, offer less sensory feedback, and require more regular maintenance. Regardless of the type of prosthesis planned for, fitting of an upper extremity body powered prosthesis within 7–30 days correlates with higher acceptance and success rates.36 Body-powered prostheses are most commonly used in burn rehabilitation and Table 47.1 describes the components of upper extremity prosthetic devices.37,38
|Upper extremity||Functions||Lower extremity|
|Socket||Interface between prosthesis and residual limb||Socket|
|Selective loading/pressure relief|
|Suspension||Holds prosthesis to residual limb||Suspension|
|Force transmission for function|
|Control system – Usually movement of the shoulder or chest||Links movement of a body part to the prosthesis||Control system – usually movement of the hip or knee|
|Interposed elbow joint||Performance of hand to midline||Interposed knee joint|
|Provides support during stance phase, smooth swing phase and motion for sitting and kneeling|
|Interposed wrist joint||Attaches socket to terminal device; orients terminal device in space||Shank (pylon)|
|Terminal device||Restores cosmetic appearance||Prosthetic foot|
|Replicates anatomic joints|
|Replaces hand/ankle function|
|Stable, weight bearing surface|
The rehabilitation upper extremity prosthetic goals should include: stability of shoulder girdle to allow prehension, overall ease of movement of the entire limb, energy efficient use of the device, and the appearance of a normal upper extremity. Table 47.2 describes upper extremity amputations by level and identifies the appropriate prosthetic device to address the patient’s functional needs.37,38
|Types of amputations||Prosthetic needs|
|Upper extremity||Transphalangeal||Passive for cosmesis|
|Transcarpal||Body-powered hand or hook|
|Forearm socket, wrist component, and terminal device|
|Proximal arm socket, elbow hinge (passive, active, or externally powered), forearm lever arm, wrist component, and terminal device|
|Shoulder disarticulation||Harness system and transhumeral components|
|Interscapulothoracic disarticulation||Harness system, shoulder socket and transhumeral components|
Partial foot to tibial height prosthesis
|Syme||Socket to knee, low-profile foot|
|Socket with foot and ankle|
|Transfemoral||Socket, knee joint, and ankle/foot complex|
|Socket is total contact shell, hip/knee joints, and ankle/foot complex|
The rehabilitation program for successful use of lower extremity prosthetics begins with donning/doffing of the device, transfer skills, activities to build wearing tolerance, practice to reinforce balance reactions, and pre-ambulation skills. Preparatory weight-bearing treatment for use of a lower extremity prosthesis usually begins on a tilt table, progressing to standing and then ambulation in the parallel bars. The rehabilitation goals should address stability, ease of movement, energy efficiency, and the appearance of natural gait.39 Table 47.1 outlines the common components of lower extremity prostheses and their functions.
Lower limb prosthetics require the following minimum requirements for successful use: upright trunk control, sufficient upper body strength, adequate lower body stability and control, static and dynamic balance skills, and good postural alignment. Lower extremity prosthetic fitting begins when the patient’s wounds are well-healed and will tolerate pressure and weight-bearing. Lower limb devices may be either preparatory or definitive. Table 47.2 details types of lower extremity amputations by level and identifies the appropriate prosthetic and components.37,38
Two common sequelae of traumatic amputations are phantom sensation and phantom pain. Phantom sensation is the perceived sense that the amputated limb is still present. It is not typically characterized as painful by the patient. The patient may report feeling that the amputated limb has shrunk (telescoping). In contrast, phantom pain is the sensation of pain originating in the amputated part. Upon assessment the pain may or may not be dermatomal in presentation. The patient may report constant burning, stinging, cramping, or a feeling of awkward positioning. Phantom pain is most intense acutely, gradually becomes intermittent, is worse at night, and is often exacerbated by stress/anxiety. From a therapy standpoint, phantom sensation may be managed by desensitization techniques, while phantom pain may be responsive to transcutaneous electrical nerve stimulation.
The overall process of prosthetic evaluation and fitting is described in Figure 47.22. Satisfactory use of a prosthetic device in burn rehabilitation requires continuous dialogue between the patient, therapist, prosthetist, and surgeon. Return clinic visits should include consistent prosthetic re-evaluation. However, ultimately, the use of a prosthetic device depends largely upon patient motivation.37