Key Words
burn evaluation and treatment, burns, edema management, post-operative burn therapy, rehabilitation, scar management, splinting, therapeutic exercise and activities, wound management
Synopsis
Surgery most commonly performed for post-burn injuries includes initial excision of non-viable tissue and, later, release of scars, correction of joint contractures, and use of grafts and flaps to resurface areas of skin loss. Common areas include the neck, axilla, elbow, wrist, hands, hips, and knees. Surgical procedures will vary depending on the skills of the surgeon, and outcomes are most critically affected by the availability of, and follow-up care by, an interdisciplinary burn team, including a skilled occupational or physical therapist. Burn therapists with an understanding of the principles and management of burns help to optimize outcomes from surgery and to facilitate patients’ return to normal activities of daily living. Responsibilities of burn therapists include a thorough evaluation of the patient’s history, surgical procedures performed, and assessment of physical and functional deficits. A treatment plan is then established and implemented addressing wound, edema, scar management, anti-contracture positioning, splinting, therapeutic exercises, and activities to encourage return to day-to-day activities. Successful management of burns must include the active participation of the patient and family members working together with the burn medical team.
Clinical Issues
Presentation
The incidence of burns globally in 2004 was ranked fourth of all injuries sustained, with 11 million people needing medical attention in low- and middle-income countries (LMIC). The high risks for sustaining burns are largely affected by socioeconomic conditions, age, ethnicity, and gender. In LMIC, women are primarily responsible for meal preparation and commonly sustain flame burns from cooking over low, open fires or unsafe kitchen stoves; loose clothing such as the saris worn in Bangladesh and India can easily catch on fire. Because there are no protective barriers, children may sustain burns when touching flames from similar open fires, while keeping warm when sleeping, or when tipping pots of boiling water, resulting in severe scald burns.
High incidences of injury and death occur due to lack of burn prevention programs and resources. The World Health Organization (WHO) in 2008 summarized this global problem of burn injuries and outlined strategies to decrease the incidence of burns through education and also to improve the quality of burn care, standardizing resources and expanding access to local medical rehabilitation services.
With limited resources in LMIC, lack of immediate or poor-quality medical services results in delay in wound healing and the development of hypertrophic scars and contractures. Many factors contribute to the severity of these scar contractures after initial burn injuries, including location, depth, and size of the burn, excessive edema, inflammation, immobility, and lack of follow-through of treatment by the patient as well as lack of family support. Survivors face the loss of function for performing normal activities of daily living (ADLs) ( Fig. 4.11.1 ).
International resources through non-governmental organizations (NGOs) have helped intervene in this global problem with financial donations and direct services by medical volunteers. Reconstructive surgeries to correct burn deformities have been provided by many volunteers through direct services, education, and training for local medical staff. Although surgical interventions will free up scar contractures and deformities, follow-up post-operative care is vital to achieving maximal benefits from burn reconstruction. Optimal care should be provided by a multidisciplinary team including surgeons, anesthesiologists, nurses, medical physicians, dietitians, and physical and occupational therapists. These teams work to provide not only direct care but also help with modeling the effects of working together for better outcomes.
The role of the burn therapist includes taking a thorough evaluation of a patient’s history, understanding surgical procedures performed, assessing physical and functional deficits, and providing a treatment plan in which therapeutic interventions are applied.
Post-Burn Therapy Evaluation
Assessment of post-operative surgical burn patients will determine optimal follow-up treatment. An in-depth and complete evaluation may not be possible at the initial encounter with a patient due to the acute injury and post-surgical precautions. As a patient’s condition becomes more stable, more detailed assessments may be done. The evaluation may include, but is not limited to, the following (Also refer to Chapter 4.2 on Burn Wound Management):
History of current condition:
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Age and gender, hand dominance
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Cause of burn and date of injury
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Total body surface area (TBSA) affected
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Date and surgical procedures performed
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Previous treatments and progress
Past medical history:
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Medical illnesses
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Previous injuries or surgeries
Social history:
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Family and supports
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Living environment
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Occupation
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Hobbies
Objective Evaluations
As a patient’s condition becomes more stable, assessments may be done as the patient is able to participate in testing. Therapeutic assessments may include :
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ADL: Review of functional activities that the patient needs to return to everyday life.
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Burn wound assessment: Objective components—location, depth, joints involved, color, texture, moisture ( Fig. 4.11.2 ).
Fig. 4.11.2
A body figure diagram is used in wound assessment to better document location and extent of burns. Regular reassessments help track the progress of a patient’s wound healing.
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Positioning: How does the patient hold affected structures? Does position contribute to deformity positions?
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Edema: Verbal, visual, circumferential measurements (using tape measure).
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Pain: Visual analog, numeric rating scale.
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Range of motion (ROM): Gross visual assessment of available motion, use of goniometric measurements.
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Gross/fine motor coordination: Hand dominance, ability to grasp or manipulate objects for function.
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Strength: Grip or pinch strength sufficient to engage in day-to-day activities, manual muscle testing.
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Sensation (needed to protect patient from further injury): Intact or loss of sensation to light touch.
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Scar appearance (once wound is healed): Assessment of color, height/thickness, pliability.
Burn Management and Treatment Techniques
After a thorough burn evaluation, a therapy program can then be individualized to the needs of the patient. Rehabilitation methods and therapeutic management of acute burns and post-operative reconstruction are similar: wound healing, edema control, positioning, early mobilization, scar management, therapeutic and strengthening programs, patient and family education, and training for return to ADLs. Each area of treatment will need ongoing reassessment to determine the effectiveness of the intervention.
Wound Management
Burn wound care will vary depending on the stage at which a patient is seen after burn injury. If a patient has early access to a hospital with a burn management team, wounds, infections, and development of scars and contractures can be minimized. For early acute burn wound management, please refer to Chapter 4.2 .
Reconstructive surgery may be provided later for release of contractures that develop and for application of skin grafts and flaps as needed. Initial immobilization and wound care after surgery will depend on the type of surgery performed and surgeon preference. With a full- thickness skin graft (FTSG), a bolster may be placed, applying pressure on a skin graft for better adherence. The first dressing change should be done within 5 days to check on wounds for any loss of skin, infection, excessive drainage, bleeding, or swelling ( Fig. 4.11.3 ). Dressings should be moist, non-adherent, and non-restrictive because increases in swelling may produce a tourniquet effect. Common dressings used include Xeroform and light gauze wraps. Keeping wounds moist by providing regular dressing changes helps to expedite the healing of wounds. If a wound appears overly wet or macerated, it may require a more frequent, even daily, change. Once stable with edges adhered, wounds benefit from gentle washing and rinsing. In LMIC, clean tap water may not be available, and bottled or distilled water may be used if available. Once irrigated, wounds should be allowed to dry before redressing. Dressings applied should protect the wound or grafts but not impede necessary movements for exercises and function.
Anti-Contracture Positioning
Proper positioning is vital to optimize outcomes of burn reconstructive surgeries. Placing affected limbs and tissue in optimal positions early will help to prevent excessive edema, allow optimal skin healing, prevent contractile tissue from shortening, and minimize the development of scar and joint deformities. After initial injuries or surgical scar releases, patients will often assume positions of comfort and of less tissue resistance. These positions often lead to the development of contractures. Neck burns will contract, causing the chin to become adherent to the chest, and the patient will become unable to lift the head up. Axillary burns leave the upper arm unable to reach around the body or above the shoulders for self-care and hygiene. Palmar burns and releases will tend to contract toward a flexion posture or a fist position, limiting a person’s ability to open his or her hands for function. Conversely, dorsal wrist and hand burns will pull outward to extension and will limit the ability to grasp, pinch, or close the hand. Recommendations for anti-contracture positioning vary in the literature, and general guidelines are listed in Table 4.11.1 .
| Area of Burn | Protected Position |
|---|---|
| Neck (anterior) | Midline; Neutral 0 degrees to slight extension (10–15 degrees) |
| Axilla | 90 degrees shoulder abduction |
| Elbow | 5–10 degrees from full extension |
| Forearm | Neutral to 10 degrees supination |
| Wrist | 20–30 degrees extension |
| Finger MCPs | 70–90 degrees flexion |
| Finger IPs | Neutral or full extension |
| Thumb | Between palmar and radial abduction and MCP/IP extension |
| Palmar hand | Fingers in full extension, abduction Thumb radially abducted |
| Dorsal hand | MCPs flexion, IPs extension Thumb in palmar abduction, MCP/IP extension |
| Hips | Extension, 10–15 degrees abduction and neutral rotation |
| Knees | 3–5 degrees from full extension |
| Ankles | 90 degrees dorsiflexion; neutral eversion/inversion |
Proper positions must be maintained when sleeping and throughout the day, except when a patient is actively moving, exercising, or using his or her limbs for ADLs. Educating staff and family is essential for success in positioning, because there is the temptation to make patients as comfortable as possible by adding pillows and allowing patients to assume the positions of comfort. Practice of anti-contracture positions may be reinforced with diagrams ( Fig. 4.11.4 ) or photos of proper techniques.
