Upper Limb Orthotics/Management of Burns to the Palmer Surface of the Wrist and Hand

Describe your case study
The Patient is a 32 year old Female who suffered a burn injury at home. She was making caramel for a kindergarten bake sale when she lost grip of the saucepan and spilled molten sugar over her right (dominant) hand and wrist. Due to the high viscosity of molten sugar, it stayed on the skin and continued to burn, resulting in a full thickness thermal burn to the palmer surface of the distal 3rd of the right wrist, and the medial half of the palm.

At 4 weeks from the date of injury, the wound has been debrided and necrotic tissue has been removed, skin grafting is complete and epithelial growth is established. Compression bandages have been applied to control scar hypertrophy.

The patient has 3 young children aged 3 months to 6 years. She is concerned about losing function in one of her hands, and not being able to care for them properly. She would like to be able to change nappies, cook, open jars and perform general care tasks.

Introduction

 * The upper limb is responsible for a high percentage of physical contact with an individual’s environment; as a result it is the appendage that accounts for the highest incidence of burn injuries (Smith, Munster & Spence, 1998). The hand and wrist are one of the sites most commonly associated with contractures after deep partial thickness, or full thickness burns (Klein, 2011; Dewey, Richard & Parry 2011). Splinting throughout the recovery process can assist in contracture prevention and reduce the degree of functional deficit post burn (Stal, Cole, & Hollier, 2008).

Evidence

 * Burns are an injury to tissue that can be caused by extremes in temperate, electricity, friction, chemicals, radiation or light. The treatment required and the potential long-term deficits can vary greatly subject to the degree of severity, which is determined by magnitude, and location (Shan, Hafeez & Mehmood, 2010). Burns were traditionally categorised by degree, 1st, 2nd, 3rd or 4th, respectively indicating increasing severity. Classification by depth provides deeper insight into the nature of the burn, treatment, and prognosis, making it a more convenient classification system (Smith, Munster & Spence, 1998; Price & Milner, 2012; Shan, Hafeez & Mehmood, 2010). A superficial burn indicates injury to the epidermis and upper section of the dermal papillae; characterised by pain, due to intact nerve endings, redness and perhaps blistering, resolution can occur in less than two weeks. Partial thickness burns indicate damage to the entire epidermal layer and varying degrees of damage to the underlying dermis; partial thickness burns can be subcategorised as either superficial or deep. Characterised by a creamy mottled appearance that blanches with pressure and refills upon release as well as varying degrees of pain depending on depth and nerve involvement. These burns take longer to heal and will scar. Full thickness burns destroy the epidermis, epithelial elements and dermal appendages. Characterised by a pale brown, whitish or black leathery appearance, loss of sensation, absence of blanching with pressure as well as the visibility of coagulated vessels. Full thickness burns require skin grafts, will scar, and will likely form contractures if not managed properly (Suvarna, Sivakumar & Niranjan, 2013; Smith, Munster & Spence, 1998; Qureshi & Orgill, 2012).
 * Burns are an injury to tissue that can be caused by extremes in temperate, electricity, friction, chemicals, radiation or light. The treatment required and the potential long-term deficits can vary greatly subject to the degree of severity, which is determined by magnitude, and location (Shan, Hafeez & Mehmood, 2010). Burns were traditionally categorised by degree, 1st, 2nd, 3rd or 4th, respectively indicating increasing severity. Classification by depth provides deeper insight into the nature of the burn, treatment, and prognosis, making it a more convenient classification system (Smith, Munster & Spence, 1998; Price & Milner, 2012; Shan, Hafeez & Mehmood, 2010). A superficial burn indicates injury to the epidermis and upper section of the dermal papillae; characterised by pain, due to intact nerve endings, redness and perhaps blistering, resolution can occur in less than two weeks. Partial thickness burns indicate damage to the entire epidermal layer and varying degrees of damage to the underlying dermis; partial thickness burns can be subcategorised as either superficial or deep. Characterised by a creamy mottled appearance that blanches with pressure and refills upon release as well as varying degrees of pain depending on depth and nerve involvement. These burns take longer to heal and will scar. Full thickness burns destroy the epidermis, epithelial elements and dermal appendages. Characterised by a pale brown, whitish or black leathery appearance, loss of sensation, absence of blanching with pressure as well as the visibility of coagulated vessels. Full thickness burns require skin grafts, will scar, and will likely form contractures if not managed properly (Suvarna, Sivakumar & Niranjan, 2013; Smith, Munster & Spence, 1998; Qureshi & Orgill, 2012).


 * When discussing contractures it is vital to draw a distinct comparison between wound contraction, which is a physiological stage in healing which aids in wound closure, and scar contracture, which is the shrinkage of an already healed scar (Kwan, Hori, Din, & Tredget, 2009). Healthy skin is made up of an extracellular matrix containing elastic fibres and collagen, amongst other things, that are organised in a reticular fashion allowing for integrity and stretch. After injury and during repair, this organization of new tissue does not occur, there is an absence of elastic fibres, and collagen strands within the extracellular matrix become tightly bound and cross-linked, creating a fragile, thin, and inflexible tissue. This tissue tightens over time, forming contractures (Qureshi & Orgill, 2012) that can result in the loss of full range of movement (ROM) at a joint (Goel & Shrivastava, 2010). Contractures in the hand and wrist can disrupt delicate and complex anatomy, such as superficial ligaments and tendons, that make the hand such a versatile and functional instrument of daily living (Paksima & Besh, 2012) and can lead to deformities such as claw hand, boutonnie`re, or mallet deformity (Esselman, Thombs, Magyar-Russell & Fauerbach, 2006; Kwan, Hori, Din, & Tredget, 2009).


 * In this case, the patient has acquired a full thickness burn to the palmer surface of the distal 3rd of the left wrist, and the medial half of the palm. Branches of the medial cutaneous nerve of forearm, lateral cutaneous nerve of forearm, cutaneous branches of the ulnar nerve (C8-T1), and proximally located cutaneous branches of the median nerve (C6-C8) will have been injured as a result of burn depth. Deeper structures at risk in this injury are primarily the superficial flexor tendons: flexor carpi radialis, palmaris longus, and flexor carpi ulnaris. The hypothenar fascia and palmer aponeurosis of the palmer fascia are also likely to be involved (Moore, Dally, & Agur, 2010). Adhesions involving these structures, or contracture of the surrounding skin would result in a difficulty, or inability to extend the wrist and fingers.

Orthotic treatment options
Use of orthotics to preserve the integrity of skin grafts, to assist in the prevention of contractures and maintain ROM in full thickness thermal burns of the upper limb is well documented and supported in the literature (Dewey et al., 2011; Smith et al., 1998; Esselman et al., 2006; Price & Milner, 2012). The aim of splinting is to stretch the scar tissue and pull the collagen fibres within the extracellular matrix into alignment in order to improve elasticity of the skin which encompasses a joint. Early intervention is preferable in order to capture and maintain the ideal hand position in the early stages of wound healing and to control restoration of ROM throughout maturation of the scar. This is supported by a number of studies which showed a relationship between early splinting and decreased contracture development (Dewey et al., 2011). Typically the position that is comfortable for a patient is a position that could promote disfigurement (Price & Milner, 2012; Dewey et al., 2011), this should be avoided where possible, and a position in opposition of the burn favoured. In this case a basic functional position, or intrinsic-plus position, of the wrist should be maintained. This is recognised in the literature as the wrist slightly extended to 20 to 30 with neutral deviation, the metacarpophalangeal joints in 60 – 80 of flexion, complete extension at the interphalangeal joints and the thumb in full abduction (Kwan et al., 2009; Dewey et al., 2011; Clarkson, 2005).

Orthotic Intervention

 * Splinting of the wrist can be static, static progressive, or dynamic. Static splints hold the wrist and hand in a secure position and are designated for graft stabilisation post surgery, and contracture prevention; modifications would be made to ensure adequate tension as ROM increases. Progressive or dynamic splinting would be used in severe cases where static splinting alone was inadequate or contractures were severe or well developed, they provide constant tension over time, and can be easily adjusted as ROM increases rather than requiring modifications (Dewey et al., 2011; Stal, Cole, & Hollier, 2008).


 * Splints are available prefabricated, and can also be custom fabricated. Custom fabrication is preferred as the individual shape and size of the patient can be considered, and volume fluctuations easily accommodated. In this case, a custom fabricated static splint would be the most appropriate choice for ease of fabrication and patient use, and should be worn at night (Kwan et al., 2009; Dewey et al., 2011). In addition to splinting, compression bandages would be applied as soon as the wounds have healed, and worn 23 hours a day to resist development of hypertrophic scars as the skin graft adheres and reorganization of collagen fibres occurs (Price & Milner, 2012; Stal, Cole, & Hollier, 2008). The splint further encourages skin restoration as excessive movement at the wound site can prolong healing (Alpers et al., 2013). The patient should be seen by a physiotherapist and occupational therapist to implement an active and passive stretching regime to prevent joint stiffness and further support tissue stretching throughout recovery (Esselmen et al., 2006).

Surgical Intervention

 * Despite extensive preventative measures, or due to a lack of adequate treatment in some cases, contractures may still form in some patients. Surgical contracture release and resection, followed by provision of a skin cover, either skin grafting or a skin flap is often indicated (Esselman et al. 2006; Motamed, Hasanpoor, Moosavizadeh, & Arasteh, 2006). Surgical intervention is not appropriate until the scar has matured, and the full extent of contracture has been made apparent, this can be in excess of a year. As with all wounds, post surgery there is the risk of new scar and contracture formation as the new skin graft or flap heals, and in many cases, splinting is recommended throughout recovery and healing in this instance also (Goel & Shrivastava, 2010). Thermal burns are the most common cause of upper limb contractures and show the most favourable response to static splinting. It stands to reason that surgical correction of contractures is a secondary choice for management given that splinting as a first resort could negate the need for surgical intervention (Puri et al., 2013).

Search Strategy
Databases – Medline, Cochrane, Proquest, Cinahl, SCOPUS(Elsevier), & Embase (ovid)

Burn OR “Burn Scar” AND Manage* OR Treatment

Contractrure OR “burn scar contracture” OR Burn OR Scar AND Brace OR Orthos?s OR Splint

Functional Aims and Goals
The main functional aim and goal of a splint for a burns patient is to immobilise the affected joints, especially after skin grafting. Immobilization of the joint provides protection and support to the graft as it takes hold and heals to prevent breakdown and infection. In addition, the maintenance of a functional hand position through splinting aims to maintain a complete range of motion through prevention of contracture.

The application of pressure in burn healing is a fundamental element in the reduction of hypertrophic scarring and assisting in the maintenance of body contours throughout the healing process. For this reason, the splint must allow room for compression bandages and/or silicone sheeting to be worn beneath, as well as contouring well with the patient’s body.

While plaster of paris (POP) and low temperature thermoplastic (LTTP) vary greatly in terms of their physical properties, their functional aims and goals in relation to clinical application within burns treatment are very similar. The main difference is the time frame within which each material would be utilized. POP backslabs provide an early, short-term intervention, and are to be used until LTTP splints can be fabricated; this can vary depending on the availability of orthotic staff and the time of patient admission (e.g. weekends or overnight). LTTP splints can be modified throughout the treatment process to accommodate the volume fluctuations common in burns patients, as well as changes in achievable ROM throughout rehabilitation. In his case, the joints requiring immobilization are the radiocarpal joint, midcarpal joint, carpometacarpal joint, metacarpophalangeal joints and interphalangeal joints, or, the joints of the wrist and fingers. The burns location on the palmer surface indicates the possibility of a flexion contracture, therefor splinting aims to preserve the patients ability to extend her wrist and fingers.

Design & Manufacturing Process
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Critique of fit
https://www.youtube.com/watch?v=GU--yOm4Dvo&feature=youtu.be

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