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Rehabilitation of the Burned Hand MerilynL.Moore,PTa,*,WilliamS.Dewey,PT,CHT,OCSb, ReginaldL.Richard,MS,PTb KEYWORDS (cid:2)Burn hand deformities (cid:2) Burn scarcontracture (cid:2)Burn rehabilitation (cid:2) Splinting theburnedhand (cid:2)Range ofmotion (cid:2)Hand therapy(cid:2) Handfunction Handsarethemostfrequentsitesofburninjury,1 complications after thermal hand injury include and proper management is essential to assure postburn edema, scar contracture, joint defor- that optimal functional recovery is achieved. mities, sensory impairment, loss of skin stability, Although each hand represents less than 3% of and restricted functional use of the hand. A brief the total body surface area, burns to the hand overview is given in this article. Other complica- are considered serious injuries and should be tions of thermal injury to the upper extremity that referredtoaburncenter.2Thethin,highlymobile ultimately affect hand function are also dorsal skin, the sensory-enriched palmar skin, considered. and the delicately balanced musculotendinous systemsareallatriskwithahandburn.Successful Postburn Edema management of the burned hand does not result Anincreaseinvascularpermeabilitycoupledwith simplyfromclosingthewound.Thehandisranked ashiftoffluidstotheextravascularspaceshould asoneofthethreemostfrequentsitesofburnscar beanticipatedfollowingthermalinjury.Insuperfi- contracture deformity.3–5 The resulting loss of cialpartial-thicknessburns,minimalfluidisleaked functionfromburnsthatincludeorarespecificto intotheextravascularspace,andedemaisminor the hands can have a devastating effect on the and transient. In deep partial-thickness and full- numerousliferolesofthepatientatanyage. thickness burns, edema is more severe (Fig. 1) When possible, burned hands are best treated and prolonged.6 As edema increases during the bytheentireburncenterteam,includingphysical first72hourspostburn,somaythepressurewithin and occupational therapists, with knowledge of the compartments of the hand. Consequently, burn wound healing and the potential problems excessive intracompartmental hand and forearm that can be anticipated. This article outlines the pressureswillimpairarteriovenousandlymphatic principlesofburnrehabilitationgenerallyaccepted function.7 incurrentburncenterpracticeandisbasedmore on the experience of the authors than on Hand Deformities controlledcomparativestudies. Thereareseveralcommonburnhanddeformities that can result from injury itself or the sequelae PROBLEMSTOANTICIPATE ofinjury. Athoroughunderstandingoftheeffectofthermal Claw hand deformity injury on the structures of the hand can minimize Clawhandcanoccurintheearlypostinjuryperiod or even avoid many burn-related problems. as a result of edema, tendon injury, or scar Some of the more commonly encountered contracture. An immediate consequence of a RehabilitationTherapiesandBurnPlasticsClinic,UniversityofWashingtonBurnCenter,HarborviewMedical m Center,Box359835,325NinthAvenue,Seattle,WA98104,USA o b ArmyBurnCenter,BurnRehabilitation,UnitedStatesArmyInstituteofSurgicalResearch,(SDEWEY),3400 s.c RawleyE.ChambersAvenue,FortSamHouston,TX78234-6315,USA c i n *Correspondingauthor. i l E-mailaddress:[email protected](M.L.Moore). ec h t HandClin25(2009)529–541 d. doi:10.1016/j.hcl.2009.06.005 an 0749-0712/09/$–seefrontmatterª2009ElsevierInc.Allrightsreserved. h Report Documentation Page Form Approved OMB No. 0704-0188 Public reporting burden for the collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Washington Headquarters Services, Directorate for Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to a penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. 1. REPORT DATE 2. REPORT TYPE 3. DATES COVERED 01 NOV 2009 N/A - 4. TITLE AND SUBTITLE 5a. CONTRACT NUMBER Rehabilitation of the burned hand 5b. GRANT NUMBER 5c. PROGRAM ELEMENT NUMBER 6. AUTHOR(S) 5d. PROJECT NUMBER Moore M. L., Dewey W. S., Richard R. L., 5e. TASK NUMBER 5f. WORK UNIT NUMBER 7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 8. PERFORMING ORGANIZATION United States Army Institute of Surgical Research, JBSA Fort Sam REPORT NUMBER Houston, TX 78234 9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES) 10. SPONSOR/MONITOR’S ACRONYM(S) 11. SPONSOR/MONITOR’S REPORT NUMBER(S) 12. DISTRIBUTION/AVAILABILITY STATEMENT Approved for public release, distribution unlimited 13. SUPPLEMENTARY NOTES 14. ABSTRACT 15. SUBJECT TERMS 16. SECURITY CLASSIFICATION OF: 17. LIMITATION OF 18. NUMBER 19a. NAME OF ABSTRACT OF PAGES RESPONSIBLE PERSON a. REPORT b. ABSTRACT c. THIS PAGE UU 13 unclassified unclassified unclassified Standard Form 298 (Rev. 8-98) Prescribed by ANSI Std Z39-18 530 Mooreetal Fig.1. Twocomplicationsofdeepburninjurythatcanbeminimizedwithintensiverehabilitationtherapyinclude edemaandscar.(A)Significantunresolvededemamayresultinlimitedmobilityandchronicjointdeformity.(B) Long-termhypertrophicscarthathasnotbeenmoldedandelongatedtomaximumlengthduringitsdevelop- mentisdevastating,withpermanentshorteningofstructuresandjointdeformity. postburn edema can be hyperextension of the as the palmar arches flatten. Flexion of the prox- metacarpophalangeal (MP) joints and flexion of imalinterphalangeal(PIP)jointsfollowsasaresult theinterphalangeal(IP)joints,whichiscommonly of this edema-imposed tension on the common referred to as a claw hand deformity (Fig. 2A). digital extensor tendon system and concurrent The severity of these deformities seems to be hyperextensionoftheMPjoints.8,9Thepredispo- edema-dependent. Hyperextension of the MP sition for MP joint hyperextension deformity to joints occurs as the dorsal skin is drawn taut by occur is intensified when the dorsal surface of the fluid shift into the extravascular tissues and the hand is also burned. Hyperextension Fig.2. Joint deformities can occur with tendon disruption, either from the original injury or from stretch or compression of damagedtendons.(A) Clawedhands withmultiple deformities, including MP hyperextension, IP flexion, and thumb radial adduction. (B) Note boutonnie`re deformity of middle digit. (C) Palmar cupping deformityisfrequentlyassociatedwithhyperextensionoftheMPjointofthethumb,withlossofthegrasping surfaceofthehand. RehabilitationoftheBurnedHand 531 contracturesoftheMPjointsmaydevelopdespite Palmarcupping deformity early surgical and well-planned therapy interven- Theconcavityofthehand’stransverseandlongi- tion, particularly in the presence of long-standing tudinal palmar arches is accentuated in cupping- edema. The ring and little fingers account for of-the-palm deformity (see Fig. 2C). Cupping of 65% of problem digits, as studied by Graham the palm can be anticipated when a burn is on andassociates.10 thepalmarsurfaceofthehand,usuallyasaresult ofacontactburn.Preciseevaluationofthedepth Boutonnie`redeformity ofapalmburninchildrenisoftendifficultbecause Thepotentialforthisdeformityismorelikelywith theepidermisisverythincomparedwiththethick- a deep burn involving the dorsum of the hand, ened calloused hand of an adult. Frequently the fingers, or thumb. Boutonnie`re deformity in the cupping deformity has a biomechanically associ- fingers (see Fig. 2B) involves the extensor appa- atedhyperextensionoftheMPjointofthethumb. ratus at the PIP joint level. This problem can be In addition to these deformities, sensory deficits the result of direct thermal injury or of tendon and loss of the stable grasping surface of the ischemia. Tendon ischemia can result when the palm should be anticipated. Palmar burns often injuredtendoniscompressedbetweentheeschar requireextensivetherapyandmultiplereconstruc- and the head of the proximal phalanx as the PIP tiveeffortstoyieldfunctionalresults.16 joint is flexed.11 The extent of damage to the extensor apparatus often is not known until in- Scar-banddeformities spected surgically.12 In all deep partial-thickness Scar bands develop when wounds cross lines of and full-thickness burns involving the fingers and tension and run perpendicular to the axis of joint dorsal hand, because immediate surgery may motion. These bands frequently cross multiple notbefeasible,involvementoftheextensorappa- adjacent joints and are found at the borders of ratus should be assumed, and it should be skingraftsandinareasthathealedbysecondary protected until viability of the tendon system is intention. Examples of common scar bands known.Anexposedtendonisatriskofdesiccation include the dorsal web spaces, the dorsal-lateral and subsequent rupture, which will also result in surfaces of the thumb and little finger, and the a boutonnie`re deformity if it is located over the palmar surface of the fingers (Fig. 3). Loss of dorsal PIP joint. Therefore, it is recommended webspaceexpansioncreatesconsiderablefunc- that all exposed tendons be kept moist and tionalimpairment.Whenthespanofthefirstdorsal exposedtendonsoverthedorsalPIPjointbeim- webspaceisshortened,thumbpalmarabduction mobilizedinextensionuntilthetendonisnolonger and circumduction are limited, and the thumb exposed.However,thedistalinterphalangeal(DIP) cannot be positioned away from the plane of the joint canbemobilized toallowlengtheningofthe palmforgrasp.Whenthespanofthewebspaces oblique retinacular ligament (ORL). Later causes betweenthefingersisdecreased,fingerabduction of a boutonnie`re deformity include flexion of the canbeseverelyrestricted.Ifthewidthofthetrans- PIP joint secondary to scar banding in combina- versevolararchisreduced,MPjointextensioncan tionwithashortenedORL.13 berestricted.Functionally,placementofthehand around objects that require spherical grasp and Mallet andswan-neck deformities any activities that require a flattened hand are Thermal injury to the terminal slip of theextensor impaired.Thumbradialabductioncanbeaffected tendoncanresultinlossofDIPjointextensionor if scar bands are present on the thenar region of malletdeformity.Injurytotheterminalslipcanbe thepalm. aresultofdirectthermalinjuryortendonischemia induced as the injured tendon is compressed Loss of skinsensation between the eschar and the base of the distal Permanent sensory deficits following thermal phalanxastheDIPjointisflexed.14 injuryshouldbeanticipated,withlimitedpotential Theswan-neckorPIPhyperextensiondeformity for improvement, in all hand burns involving the ischaracterizedbyhyperextensionofthePIPjoint dermis. Hermanson and colleagues17 studied andflexionoftheDIPjoint.Theincidenceofswan- recovery ofsensationinthegraftedhandfor2to neck deformity is most prominent in the middle 3 years postburn and found the final quality of finger.15 Several causes for PIP joint hyperexten- sensationtobeestablishedat1monthpostgraft- sionfollowingburninjuryhavebeenhypothesized, ing. Sensory loss may also occur with neurologic including extensor digitorum communis tendon damage to the upper extremity from multiple adherence, ischemic contracture of intrinsic causes, such as electrical injury, tension or muscles,jointstiffnessfromimproperimmobiliza- compressiontoperipheralnervesfromedema,or tion,andburnscarcontracture.15 improper positioning. These sensory deficits can 532 Mooreetal Fig.3. (A) Scar bands of dorsal web spaces with resultant loss of web-space expansion may create functional impairment.(B) Palmarandlateralbandingofthefifthdigitresultsinflexionandulnardeviationandplaces thedistorteddigitinthewayofmosthandactivities. affect overall hand function, including fine motor elbow24 in burn patients and can severely affect skills. upper extremity function. This formation of new bonemayoccurinsofttissuesurroundingthejoint Fingernaildeformities (Fig.4)orwithinthejointcapsuleorligaments,orit Because dorsal hand burns are common, finger- mayformabonybridgeacrossthejoint.25Insome nailsareinvolvedanddamagedfrequently.Func- instances, this abnormal deposition of bone tionally, the fingernail acts as a rigid support resolves spontaneously. In other cases, the against which the fleshy pulp of the finger can continuous presence of HO limits the functional stabilize. This stability aids in sensation during abilitiesofapatientsoseverelythatsurgicalexci- pinchactivities.Completeorpartiallossofafinger- sionisnecessary.HOisfoundmorecommonlyin nail is cosmetically disabling, andit may interfere patients with a greater than 20% full-thickness with the stability of the fingertip. A burn that burn and in patients whose wounds remain involves the surface of the fingertip often limits ungraftedforlongperiodsoftime.26,27 rangeofmotion(ROM)oftheDIPjointsecondary to wound contraction.18 These factors may contributetoproblemswithfinemotordexterity. THERAPYMANAGEMENTGUIDELINES Peripheralnerve injuries Burn rehabilitation should be initiated within the Peripheralnerveinjuriestendtooccurinassocia- first 24 hours of admission of a burn patient to tion with high-voltage electrical injuries.19–21 establish an individualized positioning, splinting, Neuraltissuehasaverylowresistancetoelectric exercise, and functional activity plan. Many of current and is particularly susceptible to injury. the complications previously described can be Hand function can be affected by both spinal minimized with early and ongoing therapy. cord injuries from current passing between Patients with severe hand burns may require contact sites around the spine and local nerve several years of scar management and recon- damage. Peripheral nerve damage is caused by structive procedures that typically involve long- direct influence of the current on the nerve and term rehabilitation. General guidelines for burn surrounding tissues and by swelling of an indi- therapy approaches are outlined in the following vidual muscle compartment. Permanent damage sections. to peripheral nerves, due to heat generated by currentflowandimmediateordelayedthrombosis oflocalvessels,islimitedtotheareaoflocaltissue Positioning damage. The median and ulnar nerves are the mostfrequentlyinjurednervesinelectricalburns, Specific positioning of the burned hand is crucial reflecting the greater frequency of hand involve- to healing with optimal results. Key components mentinsuchinjuries.22,23 ofpositioningincludeelevatingthedistalextremity tofacilitatevenousbloodflow,placinganelonga- Heterotopic ossification tionforceonhealingtissue,andprotectingviable Although heterotopic ossification (HO) is rarely joint and soft tissue structures from additional seen in the hand, it is commonly seen at the traumasuchasruptureorexcessivepressure. RehabilitationoftheBurnedHand 533 deeper hand burns. In these cases, exercises for isolated active or passive MP joint flexion, combinedwithactiveorpassiveIPjointextension, will impose less stress on this fragile extensor tendonsystem.28Repetitivefingerabductionand adduction requires contraction of the dorsal and palmar interosseous muscles, which assists in edema reduction and is generally indicated for burns of all depths.15 Edema control following theinitial72hoursshouldremainaprioritytomini- mizestiffeningofthesofttissueandlossoftendon glideandjointmobility. Finally, edema control through externally appliedpressureisfrequentlyusedinburncenters and thought to be clinically useful. Self-adherent elastic wraps have been proved to be effective onacutelyburnedandpostoperativeskin-grafted handstocontroledema.29Handedemameasure- ments can be used to document improvement with elevation, motion, and compression. The figure-of-eight technique has proven to be a reli- able and valid tool for measuring hand edema in patients with burns.30 This technique is a more clinicallyfeasibletoolthanwatervolumetry,which is considered the gold standard for hand edema assessment.30 Anticontracture positioning As with any burned body part, the position of Fig.4. HO is a common problematic complication in comfort for the patient becomes the position of burn survivors. Although HO is not directly related contractureformationduetoedemaorganization, tothehandburninjury,handfunctioncanbegreatly wound bedcontraction, and ultimatescar forma- affected. (A) The elbow is the most frequent site of tion. The forearm frequently assumes a pronated HO. (B) Although rare, bony deposits can occur at position with the wrist in flexion when a patient thesmalljointsofthehand. elevates the forearm and hand or rests the segmentonapillow.IfwristROMbecomeslimited Edema management in a specific direction, splinting the wrist in the Elevation of the hand and upper extremity is oppositedirectionwouldbeindicated.Circumfer- crucial to absorption of developing edema fluid. entialforearmburnsusuallyrequirethewristtobe The hand should be elevated above heart level positionedinslightextensionduetotheeffectsof as much as possible. It is also critical to extend gravityandthestrengthoftheflexormuscles. theelbowsufficientlytopromotevenousdrainage. Positioningofthehandmayvaryfromonether- Variousdevicescanbeusedtoelevatetheupper apist to another, but generally the antideformity extremity, including pillows, foam wedges/ position of the hand with a dorsal burn is an troughs, or slings, all supported on bedside intrinsic plus position, consisting of wrist exten- attachments,intravenouspoles,orfurniture. sion,MPjointflexion,PIPandDIPjointextension, Secondly, a patient who is alert and able to and thumb palmar abduction.31 This position participateshouldbeinstructedinactiveexercise combination can only be achieved by applying toactivatethemusclepumptodecreaseedema. a custom-fit splint. If the IP joints are not deeply The technique used to reduce edema should be burned, wrapping a gauze roll or piece of foam selectedcarefullytoavoidpotentialinjuryoffragile intothepalmandextendingitthroughthethumb tissues.Forexample,frequentepisodesofactive web space may provide adequate positioning. composite finger flexion and extension can be There is some controversy about whether the encouraged safely in superficial partial-thickness thumb should be positioned in radial or palmar hand burns. However, there is a risk of extensor abduction.32 Whichever position is used, the tendondamagewithpassivecompositeflexionin objectiveistopreservethethumbwebspace. 534 Mooreetal With deep palmar burns, the hand is usually reservoirs of skin overlying the IP joints.36 When positioned with all the finger joints extended and making afist, skinis recruited in a distal to prox- the volar thumb web space under stress to imal direction. Researchers have documented preservefingerextensionandthumbradialabduc- a 30% increase in finger length when moving tion,respectively.Thesepalmarburnsneedtobe from a position of total finger extension to positioned by a splint. Following re-epithelializa- complete fisting.36 The joints of the fingers do tion,siliconeelastomermaybeaddedtothesplint not move like a door hinge; rather, the phalanx toprovidepositioningandscarmanagement.With articulates around the head of the antecedent circumferential hand burns, the positioning segment to account for the increase in finger program will need to be modified and alternated length. basedonburndepthofeachsurfaceandthelikeli- hoodofscarcontracturedevelopment. Range of motion Emphasis is placed on the movements that Neuropathy prevention oppose the development of contractures. The The development of neuropathy is a common choice of exercise should be tailored to the problem in patients with burns.33 Specific areas individual needs of the patient. Active ROM is that must be managed carefully to prevent nerve preferred to passive ROM (PROM); however, if injury in the upper extremity are the shoulder for patientsareunabletoachievefullROMorpartici- brachial plexus injuries, the elbow for ulnar nerve pate with maximum effort, active-assisted move- lesions, and the wrist for injuries to the ulnar or ment or passive movement of the hand needs to mediannerves.Abrachialplexusinjurymayresult be implemented. Alert patients can be taught from improper positioning of the shoulder for self-range to ensure full combined tissue elonga- prolonged periods of time. Shoulder abduction tion(Fig.5).PROMintheoperatingroom,before greater than 90(cid:3) combined with external rotation excision and grafting procedures, enables the decreases the distance between the clavicle and therapisttoassessROMrestrictionsandperform the first rib, which may result in compression pain-freelengtheningoftightstructures. of the plexus. This position, when combined with Thepresenceofmultiplearticulationswithinthe posterior displacement of the shoulder, may also handmakesitparticularlysusceptibletojointand causestretchingofthebrachialplexus.33Placing scarcontractures.Toavoidjointcontracture,itis the arm in scaption position, that is, midway recommendedthatROMbeperformedtoisolated between shoulder abduction and forward flexion jointsbeforecompositeROM.CompositeROMis and in neutral shoulder rotation, may relieve this requiredtoprovidemaximaltissueelongationand compression.34 Compression of the posterior preventscarcontractureofthehand. cord of the brachial plexus by a splint or posi- Frequent exercise, performed multiple times tioning device may result in a motor neuropathy throughouttheday,isconsideredmorebeneficial intheradialnervedistribution. than one intense session. Wound and scar Certainarmpositionsputtheulnarnerveatrisk contraction is a process that is ongoing of compression as the nerve runs through the throughout the day and night and this process cubital tunnel at the elbow. When the elbow is needs to be treated constantly. Repeated ROM flexed to 90(cid:3), the ulnar nerve is susceptible to ishelpfulinmobilizingedemaandpreconditioning pressure exerted by the arcuate ligament. When the tissue,37,38 followed by sustained stress to theforearmispronated,theulnarnerveissuscep- elongate the scar as described later. Evaluations tibletoanexternalcompressionforcecreatedby should be performed with the wound and scar thesurfaceonwhichthenervelies.33Thecombi- tissueexposed,soappropriateexerciseprograms nation of these 2 positions puts the nervedoubly can be determined. When possible, ROM should at risk. Ulnar neuropathy can be prevented by also be performed in the absence of dressings positioningtheelbowinextensionwiththeforearm sothatthetissuecanbeobservedduringexercise, supinated and positions alternated for comfort. andtreatmentintensitycanbeadjustedappropri- Ulnar and median nerve involvement may be ately. Strengthening and conditioning programs a result of compression at the wrist caused by shouldbeimplemented,alongwithspecificROM extremepositionsorexcessivepressure. exercises,assoonasthepatientisabletopartic- ipateactively. Exercise and Activities of Daily Living Followingtissuepreconditioning,splints(static, Skinbiomechanics static-progressive, or dynamic) or casts can be Skinisahighlyextensibletissuewhencompared used to positively influence further gains in scar with burn scar.35 The skin overlying the dorsum tissuelengthandsubsequentROM.Staticdevices of the hand and fingers is especially flexible with demonstratethebiomechanicalprincipleoftissue RehabilitationoftheBurnedHand 535 Fig.5. ROMshouldbeperformedformaximumelongationofthehealingskinordevelopingscar.(A)Thiscanbe achievedwithactiveROMinmotivatedalertpatients.(B)Noteblanchingoverthumbjointsasoppositiontothe tip of the fifth digit is achieved, indicating maximum elongation of the scar. (C) It is difficult to obtain a full palmarexpansionactivelyinthepresenceofdevelopedscar.(D)Becausethisisafrequentinjuryinchildren,it isessentialtoinstructthechild’sparent/caregiverinappropriatetechniquesforpassiveROM. relaxation whereby tissue adapts to the stress 3.Inadditiontoscarmassage,otherdesensi- applied. Dynamic interventions cause tissue to tization treatment is recommended when elongate over time.38 By applying a constant healed or scarred areas of the hand are load, tissue responds by increasing its length, hypersensitive, as evidenced by extreme whichtranslatesintoincreasesinROM. discomfortorirritabilityinresponsetonor- mally non-noxious tactile stimulation.9 Desensitization techniques may include Modalities (1) dowel textures, with different textures Whentheburnisclosedandskingraftsarestable, of material glued onto dowel sticks; (2) modalitiesmaybebeneficial. contact,withuseofparticlessuchasrice 1. One recommended modality is paraffin, and beans; and (3) vibration, with use of which provides moist heat and seems to battery-operatedvibrators. soften skin/scar to promote increased 4.Theuseofultrasoundhasbeenreportedin ROM when used before exercise.39 It is treatingburnscarwithlimitedsuccess.40 effective at lower temperatures, so it can be allowed to cool before applying to Assistive devices healedburn/scarredskin. Age-appropriate self-care activities such as 2. Scar massage may be helpful in reducing feeding, helping with dressing changes, bathing, hypersensitivity, itch, and pain, and in applying moisturizing cream, and dressing are moisturizing and softening of the scar for waystoincreasephysicalactivity. thedurationofatreatmentsession,allow- Provision of simple aids such as built-up or ing easier and greater extensibility with extendedhandlesanduniversalcuffscanfacilitate ROM exercises and functional skills independence; however, they should be imple- training.40 mentedonlyifthepatienthasextraordinaryedema 536 Mooreetal or complicating comorbidities, as using regular thickness and full-thickness burns. Splinting or utensils and self-care items can promote ROM, other means of positioning after skin grafting to strength,andnormalizationofmovement. the hands is strongly recommended. A splint is also highly recommended for patients who are unable to actively maintain their own ROM, have Splinting adecreasedlevelofconsciousness,oraredeemed Many splints have been described to treat hand uncooperativewithtreatment.40 burns based on the customized need of each The antideformity splint (Fig. 6) positions the patient.41 Basic splinting principles should be wrist in extension, the MP joints in greater than directedtowardelongationoftissueagainstnormal 60(cid:3) offlexion,andtheIPjointsinfullextension.42 woundcontraction.Guidelinesdirectingtheuseof Thissplintisrecommendedforanyacuteandpost- splintsrelatedtothehandarebasedonburndepth, acute burned hand that assumes the edema- skinsurfaceinvolved,burnrehabilitationphase,and imposedclawhandpostureorhasinvolvementof patient considerations.40 It is generally accepted thecommonextensortendonsorextensorappa- thatnosplintisneededtotreathandburnsofsuper- ratusorhasaburnedareathatincludesthedorsum ficialpartial-thicknessdepthorifapatientisableto of the hand and digits. When skin coverage has maintainfullactiveROM.Prophylacticantideform- been achieved, additional forms of splinting can ity splinting of the hand at night may be helpful beusedtoprovidesustainedstressacrossmultiple to prevent contracture following deep partial- joints.Acompositeflexionwrap(seeFig.6)places Fig.6. Splintingcantakemanyforms,indicatedbyindividualpatientneedandstageofrecovery.(A)Aresting handsplintmayprovideadequatesupportforpositioningthehandintheemergentandpostgraftingperiod. If theextensortendonsareconsidered tobeat risk,the IPjointsareplacedinfullextension.(B)Anexample ofdynamicwristextensionsplint.(C)Castingmayberequiredtofullyholdjointposition.ThisMCPblockcast wasaptlynamedthe‘‘shovelcast’’bythe4-year-oldpatient,ashecouldstillplayinhissandboxwhilehisnew fifthfingerdorsalgrafthealed.(D)Flexionwrapsorstrapscanbeusefulinelongatingdorsalskin/scaroverIP jointsora combination ofMPandIPjoints.Stripsofself-adherentwrapofadifferentcolorareappliedover thewrappedhand,astoleratedforshortintervalsthroughouttheday. RehabilitationoftheBurnedHand 537 maximum stress on the finger extensor mecha- children. For example, dynamic splints (see nism,soitshouldbeusedonlywhenthetendons Fig. 6) are not recommended for small children areabletotoleratethisforce. because they are often difficult to keep in place. To successfully apply a sustained stress when Serial static splints or casts (see Fig. 6) may be theburninvolvesthepalmandvolarwrist,asplint morepracticalandeffectivewithsmallerchildren. should flatten the palmar arches and extend the Becauseofayoungchild’ssmallsize,handsplints digits.Thisposition,however,placestheMPjoint may have to be made longer so they can be collateralligamentsattheirshortestlength.Inthis anchored to an extended wrist; otherwise the situation,exercisestomaintaincollateralligament splint will tend to slide distally and actually place length should be balanced with splinting to elon- theextremityin adeforming position. Inaddition, gatethepalmarwoundorscar. adding extra straps orapplying thesplint with an elastic bandage or self-adherent wrap may be Pediatric considerations necessary. Cotton socks over the splint may Inadditiontothesmallsizeofchildren,thethera- preventthechildfromremovingthesplint. pist must consider other anatomic differences, Contact burns involving the palmar surface of suchasthinner,morefragileskinandhypermobile the hand and fingers are common in toddlers.43 joints. Unlike adults and adolescents, small chil- The hand should be splinted in wrist extension drendonottendtolosestrengthorjointmobility and finger extension and abduction, with the whenimmobilizedinsplintsforextendedperiods, thumb in radial abduction (Fig. 7). Splints should providedthesplintsareremovedforregularexer- be worn all night and at nap time unless joint ciseoractivitysessions. ROM is decreasing. Actions that can assist with Somesplintsthatworkwellwithlargerchildren desensitizationandminimizepalmarcontractures or adolescents are not as effective with small includeplacingthepalmanddigitsintoextension, Fig.7. Panextensionsplint,usefulinpositioningpalmarburns.(A)Elastomerputtyinsertcanbecustommolded andattachedtothesplinttoapplypressureandfullelongationwithinit.(B)and(C)Optimalpositioningofthis patientinthesplint,withwristanddigitextensionandthumbradialabduction.Notetheneedforoverwrapping tokeepthesplintinplaceinayoungchild.