The factors leading to formation of the contractural deformities

Folding bodily joints in flexion, a so-called posture of ‘comfort’, is a characteristic body posture seen commonly in a distressed individual. Although the exact reasons are not entirely clear, contraction of muscle fibers at rest and contractile force difference between the flexor muscle and the extensor muscle play an important role in the genesis of this body posture. The magnitude of joint flexion, furthermore, increases as an individual loses voluntary control of muscle movement, as frequently occurs in a burn victim (Fig. 56.1). A prolonged period of physical inactivity associated with burn treatment and scar tissue contraction around the joint structures as the recovery ensues, further impedes the joint mobility.

Figure 56.1 The posture of ‘comfort’ characterized by flexion of shoulder (axilla) and elbow joints, plus hip and knee joints is assumed by patients under distress, as in burn patients.

Incidence of burn contracture involving the shoulder (axilla), elbow and knee joints

Burn treatment that requires a long period of bed confinement and physical inactivity as well as restriction of joint movement will lead to joint dysfunction. Consequently, every bodily joint, i.e. the vertebral, mandibular, shoulder, elbow, finger, hip, knee and toe joints, are susceptible to changes. Of various bodily joints involved, the contractural deformities of the shoulder (axilla), elbow, hip and the knee are relatively common. Factors such as a wide range of joint movement and an asynchronous muscular control characteristic features of these joints, when combined with a high vulnerability to burn injuries, are the probable reasons accounting for the high incidence encountered. Recent review of the records of 1005 patients treated at the Shriners Burns Hospital in Galveston, Texas, over the past 25 years, indicated that the elbow was the joint most commonly affected. There were 397 patients with elbow joint deformity followed by 283 knee contractures. There were 248 axillary deformities. The hip joint contracture was the deformity least encountered and was noted in only 77 patients (Table 56.1).

Table 56.1 The distribution of joint deformities

The efficacy of splinting in controlling burn contractures of shoulder (axilla), elbow and knee joints

Although Cronin in 1955 demonstrated that the neck splint was effective in preventing recurrence of neck contracture following surgical release,¹ the routine use of splinting for burn patients did not become a part of the regimen of burn wound care in Galveston until 1968 when Larson, the former Surgeon-in-Chief and Willis, the former Chief Occupational Therapist at the Shriners Burns Institute, began to fabricate splints with thermoplastic materials to brace the neck and extremities.^2–5

For more than three decades, a neck brace, a three-point extension splint, and a molded brace fabricated from thermoplastic materials, the prototypes of devices used to splint the neck, elbow and the knee joints, were used in the management of burn patients at the Shriners Burns Hospital and the University of Texas Medical Branch Hospitals in Galveston, Texas. An ‘airplane splint’ similarly made of thermoplastic materials was also used to splint the axilla during the period where the use of other splinting and bracing techniques, such as a ‘figure-of-eight’ bandage, is not feasible.

A study was conducted in 1977 to determine the efficacy of splinting across large joint structures such as the elbow, axilla and knee joints by reviewing the records of 625 patients. There were 961 burns over these joints in this group of patients. Of these, 356 had involved the axillae, while 357 and 248, respectively, involved the elbow and the knee joint. The incidence of contractural deformities encountered in these joints was, as expected, low with the use of splints. The incidence of contractures in these joints was 7.3%, provided that patients had worn the splints for 6 months. The effectiveness of splinting was diminished to 55% if splinting was discontinued within 6 months. For comparison, the incidence of contractural deformity ascertained in 219 patients who had never worn the splint was 62% (Table 56.2).

Table 56.2 The incidence of contractures across the shoulder (axilla), elbow and knee joints

Although splinting and bracing were shown to be effective in minimizing joint contracture, it was not entirely clear if restriction of joint movement would affect the quality of scar tissues formed across the joint surface. The effects were assessed by determining the frequency of secondary surgery performed in this group of patients. Over 90% of 219 individuals who did not use the splint/bracing, required reconstructive surgery. In contrast, the need for surgical reconstruction in individuals who wore splints was 25%.⁶

Body positioning and joint splinting

Bodily position

Although a supine position is preferred, the patient may be placed in a lateral decubitus position while confined in bed. The head should be placed in a neutral position with the neck slightly extended. For a patient placed in a supine position, neck extension is achieved by placing a small pad between the scapulae to facilitate the scapular traction. A neck brace may be used if a patient is placed in other body positions.

Shoulder (axillary) joint

The shoulder joint is kept at 90–120 degrees of abduction and 15–20 degrees of flexion. This generally results in 60–80 degrees of arm elevation. The position is not only useful in protecting the brachial plexus from traction injury but also effective in maintaining the stability of the glenohumeral joint. The position is best kept with the use of foam wedge, trough, and/or airplane splint. A ‘figure-of-eight’ wrapping over a pad around the axilla, more frequently used for patients during the intermediate phase of recovery from the injury, is effective in maintaining shoulder abduction. It is also useful in preventing excess shoulder flexion.

Elbow joint

Elbow flexion is commonly seen in a distressed patient. Rigid flexion contracture of the elbow is a common sequela if the elbow is left unattended. With burns of the skin around the olecranon, exposure of the elbow joint is a common sequela if the elbow is allowed to contract freely. Maintaining the elbow in full extension therefore is essential. An extension brace (Fig. 56.2), or a three-point extension splint across the elbow joint is effective for this purpose (Fig. 56.3).

Figure 56.2 A splint made of thermoplastic material is used to limit joint flexion.

Figure 56.3 A ‘3-point’ extension splint manufactured similar to an orthotic device is used either to extend a contracted elbow joint or to immobilize the joint in full extension.

Wrist joint

A contractural deformity involving a wrist joint is relatively common in individuals with hand burns that were not splinted properly. A cock-up hand splint should be applied to maintain a 30° wrist extension (Fig. 56.4).

Figure 56.4 A hand splint that will maintain the DIP-PIP joints at full extension and MCP joints at 70° while keeping the wrist joint at 30° extension, i.e. the hand in a position of ‘safety’.

Hip joint

A contractural deformity of the hip is relatively uncommon unless the hip joint is allowed to remain flexed for a long period of time. Hip extension can be achieved by placing the patient in a prone position. In a supine position, 15–20 degree of abduction is maintained with the use of brace or anklet.

Knee joint

Flexion of the knee is another posture commonly assumed by a burned victim. Similar to the elbow, uncontrolled flexion of the knee joint will lead to exposure of the joint structure, especially in instances where the injuries involved the patella surface. Maintenance of knee in full extension is, in this sense, an essential component of therapeutic regimen. This is accomplished by means of a knee brace or a three-point extension splint to assure a full extension of the knee joint (Fig. 56.5).

Figure 56.5 A ‘3-point’ extension splint can be also used to manage the flexion contractures of a knee joint.

Exercise

Although exercising a burned victim is an integral part of burn therapy, it is seldom implemented until the resuscitative measures are completed and the condition of the patient is considered stable. The primary goal of exercise is to maintain functional integrity of the joint structures and the muscle strength. This is attained by, in most instances, moving the joint manually and muscles passively. Frequency and intensity of an exercise regimen, however, may vary depending upon the magnitude of injury and the extent of joint involvement. The treatment, if possible, should be intensive and is rendered as frequently as possible.

Bodily positioning and joint splinting

Joint splinting and bodily positioning are similar to the regimen used during the acute phase of burn recovery. That is, the shoulder is kept at 15–20 degree flexion and 80–120 degree abduction. A ‘figure-of-eight’ wrapping over an axillary pad is used to maintain this shoulder joint position (Fig. 56.6). The elbow and knee joints are maintained in full extension by means of a three-point extension splint or brace. A pressure dressing or garment is incorporated in the splint. In instances where the use of ‘figure-of-eight’ bandage, pressure dressing and/or garment, is not feasible because of recent surgery, devices such as an ‘airplane splint’ device (Fig. 56.7), or a three-point extension splint may be used to splint the axilla, elbow and the knee joints.

Figure 56.6 An elasticized bandage is used to wrap around the shoulder (axilla) joints in a ‘figure-of-eight’ fashion to extend and to abduct the shoulder joints. An axillary pad is included in the wrapping to increase the pressure upon the axillary fold.

Figure 56.7

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

Pathophysiology of burn shock and burn edema Enzymatic debridement of burn wounds Functional sequelae and disability assessment Reconstruction of the burned breast Pre-hospital management, transportation and emergency care Microvascular technique of composite tissue transfer

Stay updated, free articles. Join our Telegram channel

Join