Upper Limb Orthotics/Burns injury on the dorsal surface of the wrist

Describe your case study
A 20 year old student had a burn injury on his right hand from a hot water. The accident happened one week ago (1/52) at a camping picnic arranged by him. The scenario starts when he was about to prepare an early morning breakfast for others. He slipped just next to the turned on stove; which had a very hot tea pot on it. The tea pot spilled on the dorsum surface of his right hand and left him with a deep partial thickness burn injury.

The presenting complication was burn injury extended from the metacarpophalangeal joints; all the way across the wrist joint proximally 20 cm onto the forearm. Extension contracture was developed on the wrist joint 40˚ degrees, hyperextension in the metatarsophalangeal joints, and 10˚ degrees Redial deviation contracture. The patient is on Morphine, and there is no evidence of any graft/flap intervention.

Despite the burn injury he regained a normal upper limb function. The patient is right hand dominant, and he lives alone in a flat close to his university. He would like to play piano again and be able to practice his activities of daily living independently.

Introduction
Historically treatments of burns injury had been discovered and evolved a long time ago. There is evidence proving the involvement of the Neanderthal to treat burns injury for over than 3500 years (Herndon, 2012, p. 1). According to Herndon (2012), documentations form the Egyptian in 1500 BC and from the Chinese in 1600 BC had been found which explained their ways to treat burns injury. Nowadays with the massive developments of the medical sectors; Burns injury treatment and rehabilitation are sophisticated and occupies high ranking among the other medical areas.

Evidence
Prescribing the best available rehabilitation treatment option for any type of burns injury is complicated. Clinicians should have an insight and understanding of the principles of these injuries to be able to distinguish between the different types of the burns injury and their healing mechanism. Consequently, the way of the rehabilitation approach for each type of burns injury will be very specific (Radomski & Latham, 2008, p. 1243). The previous case study represents one of the cases that should be analysed from all aspects in order to prescribe a useful orthotics treatment. This will enable the patient to practice the activity of daily living independently, and facilitate the healing process. Anatomically, human skin is representing 7% of the total body weight in the average adult (Marieb & Hoehn, 2007, p. 152). It consists of epidermis which is the outer layer of the skin and has five different types of cells. The thickness of epidermis is different according to the location and function, for instance in the finger tips and palms the skin is thicker than the dorsum of the hand. The second layer is called dermis, which contains nerves ending, vessels, hair follicles, sweat glands and oil glands. The last two layers respectively are subcutaneous tissue layer which contains fat and it’s responsible for regulating the body temperature and then the muscles tissue layer (Marieb & Hoehn, 2007, p. 152-159).

Pathologically, once the burn happens the body will react by attempting to reduce the heat by dilation of the body vessels, the skin then becomes erythematous. Burns Injury will occur with additional heat to the same spot, which will then increases the permeability of the blood vessels. Consequently, the plasma will leak out from the vessels into the surrounding tissue. The local circulation becomes sluggish, which leads to the death of the cells (Leveridge, 1991, p. 10).

There are many types of burns; chemical, electrical, radiological and thermal burns which include flash, flame, contact and scalds burns injury (Herndon, 2012, p. 37&70). Leveridge (1991, p. 7), has defines the scalds burns injury as “the burns that produced by moist heat”. Hot water burns injury is considered one of the scalds burns injury, it’s an unintentional injuries that could lead in many cases to very serious consequences. Exposing the human skin for a water temperature of 60˚C for five seconds only; can lead to a partial thickness burn (Leveridge, 1991, p. 8).

The degree of the burns severity fundamentally depends on the thickness of the affected skin. In a deep partial thickness burns injury; the cells of epidermis and superficial layers of the dermis would be severely damaged (Radomski & Latham, 2008, p. 1245). According to Herndon (2012), the injury site would be very painful as the nerves ending would be more exposed and much sensitised to any stimuli. He also indicates that the pressure sensation would be intact, while the light-touch sensation is diminished. In addition, the patient would experience deep achy pain related to the inflammatory response (Herndon, 2012, p. 578).

According to Radomski & Latham (2008), the spontaneous healing process in a deep partial thickness burns injury believed to be sluggish; it could takes between three to five weeks. They indicate that the impairment of the dermal layer which has vascular content is believed to be the reason behind the slow rate healing process. Consequently, the risk of hypertonic scar formation would increase as the spontaneous healing process is decreased in speed. This will result in developing contractures and deformities; which will effects the patient quality of life significantly (Herndon, 2012, p. 635). Herndon also indicates the effectiveness of using a compression/pressure garment therapy with a conforming orthotics for a deep partial thickness burns injury. A significant reduction of the scar formation would occur and prevention of contractures or deformities.

Orthotic treatment options
The principle role of orthotic treatment in burns injury is to prevent contractures and deformities, and maintain the range of motion that could be achieved by the physiotherapy/ occupational therapy either pre- or post- surgery intervention (Turner, et al. 1996, p. 283). According to Holavanahalli et al. (2011), there are two different opinions provided in the literatures regarding the application of the antideformity splint for burns injury patient. The first school suggests the splint application before the contractures occur as prevention, while the second school suggests the application of such splint if there is any reduction in the passive range of motion (Holavanahalli et. al, 2011).

As a clinician having a patient with a deep partial thickness burns injury on dorsal surface of the right wrist, I would initially assess the range of motion of the wrist joint and Metacarpophalangeal joint and compare it with his left side. Inspect carefully the level of sensation in the finger tips by conducting some neurological tests. As the presenting complication has an explicit extension contracture on the wrist joint for about 40˚ degrees, hyperextension in the metatarsophalangeal joints, and 10˚ degrees Redial deviation contracture. I would prescribe the resting position/ intrinsic-plus position orthotic with neutral wrist position as it would be the optimum position for the wrist joint and hand to prevent the contracture (Radomski & Latham, 2008, p. 467).

According to Turner, et al. (1996, p. 267), the resting position/ intrinsic-plus position orthotic should maintains the wrist joint in 20˚- 30˚ degrees of extension (modified to neutral or 10 ˚ degrees only for this case), metacarpophalangeal joints in 70˚ degrees of flexion, interphalangeal joints in full extension, thumb opposed and extended, and web space and palmar arches are maintained. There are many evidences proved the benefits of using resting position splint to reduce the burns injury oedema (Kowalske, 2011). However, Kowalske (2011), also suggest the once the burns injury initially healed or covered; the patient might be able to mobilize his hand actively. Then an alternative splint should be customized to accommodate and maximize the range of motion.

Many studies have shown the impacts of the delay in prescribing a new splint design, which supports and increases the biomechanical advantage of the hand after the healing has occurred. Dewey et al. (2011), points out the impacts of prolonged resting position. They  recommended using the resting position splint as a night splint after the wound is completely covered. Dewey et al. (2011) believed that tightness of the intrinsic muscles of the hand could occur with prolonged resting position, which could create other deformities for instance, swan-neck deformity.

An alternative option to the orthotic testament would be the application of the serial casting method with plaster or fibreglass bandages. This option is mainly used to correct 30˚ degrees contractures and above, which is considered a significant contracture (Herndon, 2012, p. 628). According to Herndon, a new material has been recently introduced to be an alternative casting material; it is non-latex polyester such as Delta-Cast. Richard et al. (2009), indicate in their paper that the indication of serial casting is if the patient is not cooperative, does not accept the splint, and in a grafting intervention that requires protection and immobilisation.

However, for the previous case study I would apply the splinting method in a resting position/ intrinsic-plus position or antideformity position. I would use low temperature thermoplastic material including the two-thirds of the forearm length, the wrist joint, and the whole hand joints. I will keep in my consideration that this splint’s design will be subjected to some changes after 2 to 3 weeks from the incidence if the wound will be completely covered.

Comparison of orthotic treatment options
The previous case study represents a condition that has high controversy amongst the researchers of the medical field. According to Kowalske et al. (2007), some researchers argued that the outcomes from skin grafting/ flap intervention for deep partial thickness burns injury, is better in terms of accelerating the healing process and consequently decrease the rehabilitation time. However, Herndon (2012, p. 635) indicates that spontaneous healing could increase the chances of hypertonic scars to be formed in the deep partial thickness burns injury. Accordingly, the patient would be vulnerable to develop contractures and deformities which will affect his quality of life and reduce the level of activity and independence.

Functional Aims and Goals
The pervious patient presented with extension contracture on the wrist joint of 40˚ degrees, hyperextension of the metacarpophalangeal joints, and 10˚ degrees Redial deviation contracture. Therefore, the principle role of orthotic treatment should be correction of the contractures and preventing further deformities from occurring. Also, to maintain the range of motion that could be achieved by physiotherapy/ occupational therapy. Through immobilising the wrist joint therefore preventing it being extended as a result of hypertonic scar formation, and immobilisation will also help to promote tissue healing. Finally many literatures suggest that the orthotic treatment will reduce the burns injury oedema. Accordingly my goals would be:
 * A custom made resting position splint using a low temperature thermoplastic material (3.2mm), including two-thirds of the forearm length, the wrist joint, and the whole hand joints.
 * The wrist joint in 20˚- 30˚ degrees of extension (modified to neutral or 10 ˚ degrees only for this case, to achieve correction).
 * Metacarpophalangeal joints in 70˚ degrees of flexion or slightly less.
 * Interphalangeal joints in full extension or slightly flexed.
 * Thumb partial or full opposed and extended.
 * Web space and palmar arches are maintained.
 * Trim lines: align with the proximal and distal ulnar/radial bias.
 * Strap on the proximal phalanges 30-25mm, 50mm padded wrist strap, and 30mm proximal strap on the forearm.

Design
The main consideration for designing any splint is to meet the functional aims and goals, which should be the outcome from the orthotic treatment for any specific condition. Therefore, the orthotic design for the pervious patient will be:

Presenting complication (Figure No. 1)

 * Extension contracture on the wrist joint of 40˚ degrees
 * Hyperextension of the metacarpophalangeal joints
 * 10˚ degrees Redial deviation contracture

Obtained position (Figure No. 1)

 * Wrist joint in 20˚- 30˚ degrees of extension (modified to neutral or 10 ˚ degrees only for this case, to achieve correction).
 * Metacarpophalangeal joints in 70˚ degrees of flexion or slightly less.
 * Interphalangeal joints in full extension or slightly flexed.
 * Thumb partial or full opposed and extended.
 * Web space and palmer arches are maintained.

Force system diagrams (3 planes):

 * Frontal (Coronal) plane forces (Figure No. 2).
 * Transverse plane forces (Figure No. 3).
 * Sagittal plane forces (Figure No. 4).

Materials of choice:
Fast bonding and remoulding capabilities low temperature thermoplastic material LTT (3.2mm).

Attachment methods:
The remaining unpadded loops could be padded to increase area of application and disperse the force causing pressure and any irritation.
 * Velcro strap on the proximal phalanges 30-25mm.
 * 50mm velcro strap padded with neoprene or 50mm Beta Pile II™ Loop if available on the wrist.
 * 25mm velcro strap on the IP joint of the thumb.
 * 30mm proximal strap on the forearm.

Trimlines:
Align with the proximal and distal ulnar/radial bias.

Manufacturing procedure:
The following materials must be available to ensure the quality of the produced orthotic: Electric heat pan – LTT sheet 3.2mm – heat gun – velcro strap 25/30-50mm loop and adhesive hook – neoprene or 50mm Beta Pile II™ Loop – clean paper for tracing the pattern – curved scissor.

Manufacturing process

 * Trace the effected hand if it’s applicable or the unaffected hand in case of any difficulty, including two-thirds of the forearm length. Identify the appropriate bony landmark. Mark the base of the first and second web space, to landmark the end of the cut line for the thumb piece (Figure 5 & 6).


 * Draw the pattern as it is shown in (Figure 7 & 8) allow for at least 1cm extra of material around the hand to ensure a secure contouring.


 * Cut the tracing paper and try it on the patient to check the fitting appropriateness.


 * Sketch the tracing on the LTT sheet (Figure 9). Use the heat pan to cut out the pattern and shape with scissor. Note the final shape of the resting splint pattern in (Figure 10).


 * Place the pattern in the heat pan to prepare it for the moulding (Figure 11).


 * Make sure when removing the material from the heat pan to hold it as it is illustrated in (Figure 12); to avoid any stretching in the material. Make sure to dry it from the water and place the splinting material on the patient’s hand.


 * The patient must be seated, the arm should be positioned with the elbow supported, the forearm in a vertical position. The clinician must stand in an open space (Figure 13).


 * Orienting the required alignments of the wrist joint, MCPJ, phalanges and the thumb, and hold the position until the splinting material is properly moulded (Figure 14).


 * Make marks if any adjustments and trimming needed and mark the straps position (Figure 15 & 16).


 * Roll back the edges of the splint and flair the proximal end to increase the splint cosmoses and ensure the smoothness. Apply the adhesive hook; make sure to heat the adhesive hook as well as the sites of the material where the hook will attach to onto the splint (Figure 17 & 18).  Attach the padded straps to the hook allowing sufficient length to cover the patient hand, wrist and forearm.


 * Note the final outcome shape of the resting splint (Figure 19, 20, 21 & 22).


 * Fit the splint on the patient and provide him with wear and use instructions (Figure 23, 24, 25 & 26).

References:
Fess, E. E., Gettel, K. S., Philips, C. A., & Janson, J. R. (2005). Hand and Upper Extremity Principles & Methods. (3rd Ed.). United States of America: Mosby, Inc.

McKee, P., & Morgan, L. (1998). Orthotics in Rehabilitation – Splinting the Hand and Body. (1st Ed.). Philadelphia: F. A. Davis Company.

Wilton, J. C., & Dival, T. A. (1997). Hand Splintting – Principles of Design and Fabrication. (1st Ed.). London: WB Saunders Company Ltd.

Critique of fit
Subjective and objective assessments has been conducted for Allen who is received a deep partial thickness burn injury 1/52 ago on the dorsum surface of his right hand. The aim of the assessment was to investigate closely his functional limitation after the incident, and prescribe the optimum position of his hand splint. A LTT custom made resting position splint extending into two-thirds of the forearm length, the wrist joint, and the whole hand joints has been prescribed. Most of the functional aims and gaols which were mentioned above in (section two Functional Aims and Goals) have been implemented practically and achieved including the obtained position and the trim lines as well as the straps position. However, there are some aspects which need to be highlighted to prevent other clinicians repeating such errors in the future. These aspects include:


 * The initial plan was to use a (3.2mm) thickness of low temperature thermoplastic material. However, due to lack of this material in the clinic; I customised the orthotic with (2.4mm) perforated LTT and then reinforced it from the volar aspect with the same material (Figure No. 27).  Thus the reinforcement might decrease the ventilation of the splint and may create other skin problems.


 * The 50mm velcro wrist strap was initially to be padded with neoprene or 50mm Beta Pile II™ Loop. However, the clinic was running out of these two materials which necessitated me to use any available soft material.  Plastazote 3mm was the only available option as a padding material and I utilised it for all straps.  Although padding all straps will increase areas of application and disperse the force causing pressure and any irritation.  But it might also reduce the ventilation of the adjacent area.  Furthermore, there are no permanent straps (adhering to the LTT), all of them are attached to adhesive hook from both ends, as we might need to replace them at some point of time.


 * The internal surface of the orthotic was overall smooth, with the exception of the first web space of the thumb. These wrinkles might be uncomfortable as it will create a pointed pressure for the adjacent soft tissue (Figure No. 29, 30, & 31).

Outcome measures
The principles of Allen’s resting splint were correct the contractures and prevent further deformities from occurring. In addition to maintaining the range of motion that could be gained through physiotherapy/ occupational therapy. Finally, immobilising the wrist joint; thus preventing it extending as a result of hypertonic scar formation, promote tissue healing, and reduce the burns injury oedema. Upon the pervious orthotic treatment aims; I would choose an outcome measure for each aim individually.

1.	Correct the contractures and prevent further deformities from occurring:

This aim could be measured by comparing the range of motion of the affected wrist which was recorded during the objective assessment in the first visit, with the ROM which recorded in the second visit (e.g. after one week). Any progress in the second ROM reading will indicate a positive outcome measure towards the orthotic treatment and the chosen position.

2.	Maintain the range of motion that could be gained through physiotherapy/ occupational therapy: Following the orthotic intervention; Allen should receive another referral to other adjunct therapy (in his case occupational therapy), to monitor his rehabilitation progress. The orthotic should sustain the ROM achieved by the occupational therapy treatment. Thus, the increase in ROM measured each visit compared with the previous visit should be considered a positive outcome measure.

3.	Immobilising the wrist joint will prevent it extending as a result to hypertonic scar formation, promote tissue healing, and reduce the burns injury oedema:

Measuring the outcome of this aim would be subjective; by visual observation of the patient’s hand and comparing it with previous visual observation. It could be done during the follow up appointment with the plastic surgeon and/or through the burn unit by nurses, as they are specialised in wound management, and monitoring the wound healing and/or oedema. The reduction in the wrist extension moment due to the pull of the hypertonic scar, and the positive progression of the wound healing as well as the oedema, would be consider a positive outcome measure.

From the subjective assessment we know that Allen is right handed, and he lives alone in a flat close to his university. He also reported that he would like to play piano again and be able to practice his activities of daily living independently. Allen has been on Morphine due to severe sharp pain on the affected areas. Accordingly, a visual analogue pain scale could be considered as an outcome measure for Allen’s pain before and after the orthotic intervention. However, it is vital to consider the activities of daily living and how they been affected with the pain presence in this case. Therefore, I have chosen the Pain Self Efficacy Questioner (PSEQ) by (Nicholas, 1989). The aim of this questioner scale was to identify whether the client is confident or not at present to do some activities with the exception of the pain. For example, social activities, hobbies, activities of daily living, etc. Comparing the second visit questioner with the first visit, Allen has a slightly significant improvement in his confidence especially in the area of normal lifestyle and starting to become more active (Figure 32 & 33).

References:
Nicholas, M. K. (1989). Self-efficacy and chronic pain. Paper Presented at the Annual Conference of the British Psychological Society. St. Andrews. Retrieved from: Victorian WorkCover Authority (VWA) http://www.worksafe.vic.gov.au/forms-and-publications/forms-and-publications/pain-self-efficacy-questionnaire-pseq

Referral letter
29th May, 2014.

Tegan Blackmore

The Royal Melbourne Hospital

Occupational therapy department

RMH, Victoria 3050

Australia

Occupational Therapy Referral
Dear Mrs Tegan,

Please accept the referral of Allen, a 20 years old man presented to our clinic with deep partial thickness burns injury from hot water to his right hand and wrist (dorsal side) 1/52 ago. In his treatment I have provided the following:  Hand splint with 10˚- 0˚ wrist extension as a resting position, MCP joints at 70˚ flexion or slightly less, IP joints in full extension or slightly flexed and the thumb opposed and extended. The first web space and palmer arches are maintained. I have chosen this design to correct and prevent the contracture deformity, maintain functional position and immobilize the burnt areas. This position should prevent the hand form developing “claw hand” deformity.

Allen lives alone in a flat close to his university which means practicing his ADLs independently with no assistance, which means risk of re-injury or scratches to the burnt area. Another issue is the itching which occurs with burns healing process and to splint the area in the early stage would prevent further damage to the burnt skin. The compression or pressure garment would assist in preventing hypertrophic scarring and skin contractures. This could be worn and the splint applied over it, in addition to therapeutic and rehabilitative activities as an important consideration as a part of recovery and healing. For this reason I would strongly suggest that Allen consults an occupational therapist. Therefore, I would like to ask for your services and input as an occupational therapy department to further improve the rehabilitation outcomes for Allen, can you please assess and treat (where applicable) for the following:  Prevent hypertrophic scarring and skin contractures through the provision of the applicable pressure garment and scar management techniques. Functional hand assessment and restoration where deficit is present especially in fine finger movement skills.

I need also to inform you that once the burns injury has healed well; I could reassess Allen’s hand and make another splint; only splinting the wrist joint and leave the digits free (functional wrist splint). This would allow freedom of function but at the same time protect the burn area from complications and further injuries. It’s his dominant hand and despite the challenge in using it with the injury; Allen is encouraged to use his hand in daily functions where ever possible to allow normal progress and development resulting in improved hand muscles strength and sensation.

Regards,

Husain Skinner Prosthetist & Orthotist

National Centre of Prosthetics & Orthotics La Tobe Univercity

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