Orthoses for the Burned Hand

Key Points

Burn injuries involving the hand commonly result in contracture deformity. Deep burns can result in more than just an unacceptable appearance; these patients also experience profound functional consequences for the burned hand, such as loss of fingertips, mutilated nails, joint limitation, and painful scars.
Splints are important in the management of a burned hand, and the type of splint used depends on the location of the burn and the anticipated deformity.
For dorsal surface hand burns, the splint should position the hand in the angle of antideformity, also referred to as intrinsic plus position. Palmar surface burns should be positioned in a palmar extension splint.
A circumferential hand burn may require splinting in an alternating intrinsic plus position splint with the palmar extension splint during each day.
If patients are unable to adequately participate in active range-of-motion exercise programs once the wound has epithelialized, dynamic splints may be necessary.

Types of burn injury include flame, scald, flash, contact, chemical, and electrical. Flame and scald burns are most common and make up more than 75% of burn injuries requiring hospital admission in the United States. Roughly 39% of burns involve the upper extremity. The hands account for less than 5% of total body surface area, and although hand burns do not often play a major role in mortality, they are important factors in successful reintegration into society and professional life after discharge from the hospital. Despite this small percentage, burns involving the hand are considered severe injuries meeting criteria for referral to a specialized burn center for individualized care. Adults have a lower incidence of palmar burns, because the hands are used to protect the face against a severe burn trauma and thereby only the dorsal parts of the hands are exposed. The skin of the hand has a wide range of thickness, and the skin over the dorsum of the hand is much thinner than that over the palmar surface.

Burn injuries are classified according to their size and depth of tissue injury, and this classification determines treatment protocols and delineates expected healing rates. First-degree and superficial second-degree burns typically heal satisfactorily within about 2 weeks and have good functional and aesthetic results. Deep second-degree (partial skin thickness), third-degree (full skin thickness), and fourth-degree (tendon, bone, nerve, or joint involvement) burns take longer than 2 weeks to heal and predictably heal by scar tissue formation.

Burn rehabilitation can be classified into three components. Table 15.1 summarizes the basics of burn rehabilitation protocols.

TABLE 15.1

Overview and Goals of Postburn Rehabilitation

Data from Kamolz LP, Kitzinger HB, Karle B, Frey M. The treatment of hand burns. Burns . 2009;35(3):327-337; Rowan MP, Cancio LC, Elster EA, et al. Burn wound healing and treatment: Review and advancements. Critical Care (London, England). 2015;19:243; and Serghiou M, Cowan A, Whitehead C. Rehabilitation after a burn injury. Clin Plast Surg. 2009;36(4):675-686.

Stage	Time Frame	Therapeutic Exercise	Splinting Goals	Splint Types
Acute	The time from admission until about the time that a patient's wounds are 50% closed or the use of skin grafting to achieve wound closure has begun	-Active ROM exercises are used to counteract the effects of prolonged bed rest and muscle atrophy, maintain joint ROM, and prevent contractures. -Active assistive ROM exercises are used when a patient cannot actively move through the full ROM. -In conditions in which patients cannot participate actively, passive exercise is used to maintain ROM, assess joint motion, and elongate tissue. -Resistive exercises are used to maintain or increase strength, ROM, proprioception, and coordination.	Used for positioning and alleviation of edema; serially adjusted to counteract scar contracture	Static splints
Intermediate	The time frame from about 50% of wound closure to the time of complete wound closure	-Focus shifts to prevention of functional impairment as patients begin to achieve wound coverage and to sustained stretching of the affected areas, with increased frequency and intensity of active ROM and strengthening exercises. -Sustained stretching is considered to be one of the most effective methods to combat the strong destructive forces that lead to contracture formation. -Strengthening exercises change from manual resistance to the use of weights and resistive tubing. -Areas of concentration include those where weakness is found during strength assessments and the muscles opposing scar tissue contractures.	Essential for positioning and stretching/lengthening of contracted tissues	Static splints, static progressive splints, or dynamic splints
Long term	The time frame from wound closure or patient discharge from the acute hospital setting until such time that a patient has received maximal benefit from rehabilitation services	-Patients will learn a home exercise program and address the overall conditioning so that therapists can focus on exercises and stretching that promote the restoration of movement and function. -If deficits in ROM are present, the therapist should treat the limitation in motion rather than working to increase the patient's strength, because normal, healthy muscle is unable to generate the force required to elongate burn scar tissue.	Used to provide stretch, promote tissue gliding, decrease stiffness, and strengthen weakened structures	Static progressive and dynamic splints

ROM, Range of motion.

Deep burns can result in more than an unacceptable appearance. Profound functional consequences for the burned hand, such as loss of fingertips, damaged nailbeds, joint limitation, and debilitating scars may also develop. The patient must be motivated to cope with and rehabilitate these problems. Restoration of function and appearance is the ultimate goal of postburn treatment. Prevention of deformities is easier to manage than direct deformity correction. Prevention depends on successful early intervention and consistent patient participation.

Pathophysiology

The typical deformities seen in the burned hand are hyperextension of the metacarpophalangeal (MCP) joints, flexion deformity of the interphalangeal (IP) joints, loss of the transverse metacarpal arch, adduction contracture of the thumb, flexion contracture of the wrist, and shortening of the dorsal skin ( Fig. 15.1 ). The MCP joint assumes the hyperextended position as a result of joint edema. The MCP joint collateral ligaments are relaxed when this joint is extended. This allows increased volume within the joint to accommodate edema. In contrast, edema in the IP joints results in a flexed posture and tightening of the volar plate. Persistent edema, infection, poor compliance with hand therapy, ineffective splinting, prolonged immobilization, and loss of skin coverage all contribute to the development of burned hand deformities. Success is best measured by restoration of function, which often correlates with an improvement in appearance.

Figure 15.1, The most common deformity after a dorsal burn is the clawhand deformity, which positions the digits into hyperextension of the metacarpophalangeal joints, flexion of the interphalangeal joints, loss of transverse metacarpal arch, adduction contracture of the thumb, flexion contracture of the wrist, and shortening of the dorsal skin.

Initial Assessment

Ideally, rehabilitation of the burned hand, including involvement of a burn-trained therapist, should be instituted as soon as feasible after the thermal injury. The treatment plan is directly influenced by the depth of the burn and the requirement for surgery. Superficial burns that do not require skin grafting are treated with wound care and early active range-of-motion (ROM) exercises. These patients usually do not develop contractures and do not require splints. Deep partial-thickness and full-thickness burn wounds are typically treated with early excision and grafting. The goal of early excision of damaged tissue and skin grafting is to minimize the secondary problems of scar formation and contracture. Early excision is important for reducing the inflammatory phase, expediting wound coverage and healing to allow for earlier active motion rehabilitation. At the time of excision and skin grafting, the patient is typically placed in a volar intrinsic plus Orthoplast splint, which remains in place for 3 to 5 days to optimize revascularization of the skin graft. The intrinsic plus position maintains the IP joints at 0 degrees of extension, the MCP joints in 70 degrees of flexion, the thumb in abduction, and the wrist in 15 to 30 degrees of extension. The splint immobilizes the hand and wrist to decrease shearing of the skin graft from the wound bed and increase the likelihood of graft adherence.

Treatment and Recommendations

Structural Considerations

Treatment of burns that involve the hand is complicated by the potential for exposure or injury to numerous important structures, including tendons, bones, and joints. Therefore splinting and therapy protocols can be distinctly different for burns involving the dorsal surface of the hand compared with the palmar surfaces. The skin over the dorsum of the hand is thin, supple, and highly mobile, which allows for gliding of the underlying extensor tendons. When the dorsal surface is involved in burn injuries, significant functional disturbances may result. The close proximity of the underlying extensor tendons, especially on the dorsal surfaces of the fingers, makes these areas prone to tendon injuries and may result in deformities such as mallet finger, boutonnière, and swan neck deformities. When performing excisions of dorsal burns, it is critical to preserve the extensor tendon apparatus, including the terminal extension, lateral bands, and central slip, when possible.

Palmar hand burns also result in significant deformities that can be very difficult to correct. Serious burns to the palmar surface of the hand commonly cause devastating and sometimes uncorrectable flexion contractures. These burns can result in loss of the first web space, thus compromising use of the thumb. Fortunately, palmar burns are typically partial thickness and do not require excision and grafting because of the thick nature of the skin in this region.

Sensory nerves of the hand can be injured both by the burn and possibly by required excision and débridement. Sensory involvement of both the dorsal and palmar surfaces poses an even more complex challenge. Circumferential full-thickness burns and electrical burns of the hand can result in compartment syndrome and subsequent nerve and muscle damage. Early escharotomies and compartment releases may be necessary to prevent muscle loss.

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