Rehabilitation of Hand Burn Injuries

Original Editor - Rania Nasr

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Introduction[edit | edit source]

Burn Hand.jpg

The importance of rehabilitation of burn injuries has been increased due to the improved short and long survival rate of people with large burns. Successful outcomes following hand burn injury require an understanding of the rehabilitation needs of the patient. Rehabilitation of hand burns begins on admission, and each patient requires a specific plan for range of motion and/or immobilization, functional activities, and modalities. The rehabilitation care plan typically evolves during the acute care period and during the months following injury[1].

  • Burn injuries in hands are complex and the appearance of contractures is a common complication.
  • Hand burn injuries often result in limited functionality and flexion/extension of fingers and present a major hindrance in rehabilitation. These injuries also decline the quality of life, especially when included in larger burns[2].
  • The aim of physical therapy and splinting after hand burn injury is to maintain mobility, prevent the development of the contracture and to promote the functionality of hand and good cosmetic results. [3]

Physiotherapy: Problems to Be Addressed[edit | edit source]

The common deformities after burns are: claw deformity, palmer contractures, syndactyly or webspace deformity, hypertrophic scarring and amputation[3]. A position programme should start from the day of admission for any burn injury with the goal of minimising edema, maintaining soft tissues in elongated position and preserve function. splinting is an extension of positioning in anti deformity position

Application of physical therapy and splinting after burned hand injuries is very important and consists in prevention oedema, contracture, maintaining or improving range of motion, functional recovery, preventing of development of keloids scars, muscle force and good cosmetic results, reduce infection and secondary complications, good to normal strength is achieved, and self-management of symptoms.

A comprehensive understanding of the effect of hand thermal injury can improve rehabilitation outcomes and prevent burn-related issues. There are some common complications following a thermal injury to the hands[4], including:

  • Oedema
  • Joint deformities, claw deformity, palmer contractures
  • Scar contracture, hypertrophic scarring
  • Restricted or reduced hand function
  • Syndactyly or webspace deformity
  • Amputation

Post-Burn Oedema[edit | edit source]

The cause of the oedema is the increased vascular permeability following a thermal injury to the hand combined with a shift of fluids to the extravascular space. This should be taken into consideration in the rehabilitation period. The severity of oedema depends on the severity of the burn. In superficial partial-thickness burn, there is only a minimum amount of fluid leak into the extravascular space, making the oedema minor and transient. Contrarily, deep partial-thickness and full-thickness burns lead to a bigger, more prolonged and severe oedema[4].

Suggested treatment includes:

  • In acute phase from the first-day positioning of the extremities, hands elevated above the level of the heart for 24 hours, passive mobilization in affected joints and surrounding nodes (give good results in the reduction of oedema).
  • In the post-acute phase to decrease oedema retrograde massage, three times a day, bandage, elevation of the hand and passive/active movements, three times a day 10-20 repetition.
  • Electrical stimulation helps reducing hand burn oedema and improves the active motion of the hand[5].[3]

Joint Deformities, Claw Deformity, Palmer Contractures[edit | edit source]

The hand is ranked among the three most frequent sites of burns scar contracture deformity[6]. It occurs during the early post-injury period resulting from oedema, scar contracture or tendon injury[1]. This 5 minute video explains the protected position of the hand for best hand outcomes

[7]

Example of physiotherapy below.

  • Patients with hand burn injuries, For example, at day 6, may be allowed to have a splint applied.
  • To prevent a flexor contracture the protected position of the hand for best hand offers the best outcomes using a volar splint (IP joints in extension, MCP joints 60º to 90º flexion, wrist in a neutral position, thumb kept in 20º to 30º of abduction). The splint may be maintained continuously for 6–7 weeks and after 6–7 weeks until 3-month splints were used only during the night.
  • Continue to use passive/active motions and stretching exercise.[3]

Scar Contracture and Hypertrophic Scarring[edit | edit source]

Hand burn scar contracture can be classified as follows[6]:

  • Grade I -Symptomatic tightness but no limitations in range of motion, normal architecture
  • Grade II - Mild decrease in range of motion without significant impact on activities of daily living, no distortion of normal architecture
  • Grade III - Functional deficit noted, with early changes in normal architecture of the hand
  • Grade IV - Loss of hand function with significant distortion of the normal architecture of the hand

This video (9 minutes) is worth watching for physiotherapists involved in managing hand burns.

[8]

To avoid contractures:

  • Properly position (see above and video below)
  • Stretching exercise
  • Massage
  • Passive/active movements [9].

For example, Acute/subacute phase - postural alignment, splinting and passive mobilization in affected joints three times a day 10-20 repetition. Chronic phase use massage with gel (contratubex or dermatix) 2 to 3 times daily, passive/active movements and stretching exercise. The Client wears gloves.[3]

Contractures lead to major disabilities

  • Not easily reconstructed by surgery (typically an intrinsic minor/claw hand position, MCP joints are fixed in hyperextension PIP fully flexed).

Restricted or Reduced Hand Function[edit | edit source]

Physiotherapy rehabilitation is an essential component of burn care to:

  • Maintain the functional range of motion of the hand
  • Maximize function
  • Prevent contractures
  • Improve psychological health[10].

Examples of treatment

  • To maintain or improve joint ROM: passive/active range of motion in affected joints: passive mobilization. Passive mobilization after 3 or 5 days if treated conservatively, after one week if treated surgically. Passive mobilization continues for 4 to 6 weeks. Active mobilization begins after 1 week and continues until 5 to 6 month. Patients do several times a day 10-20 repetition.
  • To prevent muscle atrophy, static exercises and strengthening exercise should be performed several times a day, For example, theraband with precautions maintain or regain muscle force and active function of the hand, different kind of toys, small balls, plasticine can be employed See Hand Exercises
  • During the rehabilitation, the patients and patient’s parent are instructed to learn the home exercise plan.[3]
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Conclusion[edit | edit source]

Physical therapy and splinting is an essential part of rehabilitation in hand burns. Physical therapy and splinting should be started immediately after the injury, playing an important role in the hand function restoration.[3]

References[edit | edit source]

  1. 1.0 1.1 Moore ML, Dewey WS, Richard RL. Rehabilitation of the burned hand. Hand clinics. 2009 Nov 1;25(4):529-41.
  2. Cowan AC, Stegink-Jansen CW. Rehabilitation of hand burn injuries: Current updates. Injury. 2013 Mar 1;44(3):391-6.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Rrecaj S, Hysenaj H, Martinaj M, Murtezani A, Ibrahimi-Kacuri D, Haxhiu B, Buja Z. OUTCOME OF PHYSICAL THERAPY AND SPLINTING IN HAND BURNS INJURY. OUR LAST FOUR YEARS’EXPERIENCE. Materia socio-medica. 2015 Dec;27(6):380. Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4733548/ (last accessed 24.3.2020)
  4. 4.0 4.1 Moore ML, Dewey WS, Richard RL. Rehabilitation of the burned hand. Hand clinics. 2009 Nov 1;25(4):529-41.
  5. Edgar DW, Fish JS, Gomez M, Wood FM. Local and systemic treatments for acute edema after burn injury: a systematic review of the literature. Journal of Burn Care & Research. 2011 Mar 1;32(2):334-47.
  6. 6.0 6.1 Sabapathy SR, Bajantri B, Bharathi RR. Management of post burn hand deformities. Indian journal of plastic surgery: official publication of the Association of Plastic Surgeons of India. 2010 Sep;43(Suppl):S72.
  7. D Mastella Protected Position of the Hand Available from: https://www.youtube.com/watch?v=QwoLAcTHCxY&app=desktop (last accessed 8.4.2020)
  8. Burn Unit Series - "Stretching, Scar Management, and Compression" (UI Health Care) Available from: https://www.youtube.com/watch?v=da389tmq62g&t=270s (last accessed 8.4.2020)
  9. Rrecaj S, Hysenaj H, Martinaj M, Murtezani A, Ibrahimi-Kacuri D, Haxhiu B, Buja Z. OUTCOME OF PHYSICAL THERAPY AND SPLINTING IN HAND BURNS INJURY. OUR LAST FOUR YEARS’EXPERIENCE. Materia socio-medica. 2015 Dec;27(6):380.
  10. Dunpath T, Chetty V, Van Der Reyden D. Acute burns of the hands–physiotherapy perspective. African health sciences. 2016;16(1):266-75.