Rehabilitation of Hand Burn Injuries

Original Editor - Rania Nasr

Top Contributors - Rania Nasr, Lucinda hampton, Shaimaa Eldib, Kim Jackson, Nikhil Benhur Abburi, Aya Alhindi, Anas Mohamed and Chelsea Mclene  

Introduction

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.

• 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.
• 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. 

Problems to Be Addressed

The common deformities after burns are: claw deformity, palmer contractures, syndactyly or web space deformity, hypertrophic scarring and amputation.

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.

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, including:

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

Below is a brief explanation of these complications:

Post-Burn Oedema

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.

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 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.

Joint Deformities, Claw Deformity, Palmer Contractures

The hand is ranked among the three most frequent sites of burns scar contracture deformity. It occurs during the early post-injury period resulting from oedema, scar contracture or tendon injury.

Example of physiotherapy below.

• Patients who hand burn injuries in a palmer part after eg day 6, may be allowed to have a splint applied.
• To prevent a flexor contracture a volar splint, with the interphalangeal joints in extension and the metacarpophalangeal joints at 60º to 90º of flexion, wrist in a neutral position and the thumb kept in 20º to 30º of abduction. Changed the position of splint after 4 weeks in extension. 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.

Scar Contracture and Hypertrophic Scarring

Hand burn scar contracture can be classified as follows:

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
Subset classification for Grade III and Grade IV contractures: A: Flexion contractures, B: Extension contractures, C: Combination of flexion and extension contractures

To avoid contractures, a burned hand must be properly positioned, ranged or splinted. a Volar splint, rubber bands, stretching exercise and passive/active movements must also be used to prevent contractures. eg In acute phase and subacute phase use postural alignment, splinting and passive mobilization in affected joints three times a day 10-20 repetition. In chronic phase use massage with gel (contratubex or dermatix) two or three times a day, gloves, passive/active movements and stretching exercise. The patients repeat this several times a day.

Contractures lead to major disabilities that are not easily reconstructed by surgery. The typical contracture is an “intrinsic minus” position where the metacarpophalangeal (MP) joints are fixed in hyperextension and the proximal interphalangeal (PIP) joints are fixed in a position of flexion. The collateral ligaments of the MP joint are the most important structures of the burned hand. For this reason, positioning of the burned hand should place the MP joints at maximum flexion (90 degrees of flexion) to maximally stretch the collateral ligaments. The anatomic position for splinting is not the “Fosters Beer Can” grip but rather involves 30 degrees of wrist extension, MP joints at 90 degrees of flexion, and IP joints fully extended. The thumb should be fully abducted . To manage keloids scars we used postural alignment, splinting, passive/active mobilization, massage and stretching exercise.

Restricted or Reduced Hand Function

Physiotherapy rehabilitation is an essential component of burn care. Especially to maintain the functional range of motion of the hand, maximize function, prevent contractures as well as to improve the psychological health. Passive/ active movement and strengthening exercises using theraband with precautions have been used to maintain or regain muscle force and active function of the hand with positive outcomes.

Examples of Physiotherapy

• To maintain or relocation passive/active range of motion in affected joints and passive mobilization for each joint of the hand. Start passive mobilization after 3 or 5 days cases treated conservatively and after one week in cases that have surgical treatment. 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.
• Different kind of toys, small balls, plasticine can be employed. During the rehabilitation, the patients and patient’s parent are instructed to learn the exercise and to do them at home.