Dressings

Dressings are used to protect the wound and provide an optimum environment for healing. Dressings may be the adherent or non-adherent type, and they can serve a number of purposes, including infection control, comfort, wound immobilization, fluid absorption, debridement, and early pressure.13,17 Numerous dressing products and wound care/dressing change schedules are available. The selection of dressings and topical agents depends on the type and status of the wound; it also is often influenced by the physician’s preference. Therapists must work closely with the physician so that they fully understand the dressing program and the rationale for it.

Positioning

Positioning is important in the early phases of burn recovery to minimize edema, because edema can cause ischemia, intrinsic muscle tightness, deforming positions, loss of motion, adhesions, and fibrosis. Edema is a natural component of the wound healing process, and burns create local and systemic responses.²¹ Postburn edema develops rapidly within the first hour, peaks up to 36 hours after injury, and usually resolves within 7 to 10 days.²⁰ Edema still present in later stages is a matter of great concern.

Precaution. To prevent a decrease in arterial flow to the hand, elevate the hand to heart level only in the emergent phase.²⁰

In addition to elevation, use pressure techniques (for example, compression wraps, sleeves, or gloves) as needed, taking care to monitor circulation and skin integrity, because fragile wounds and scars break down easily.

Positioning is also used to prevent loss of motion from soft tissue shortening. The position of comfort typically is that of shoulder adduction and internal rotation, elbow flexion, wrist flexion, and thumb adduction. Loss of motion can occur in joints not even involved in the burn injury. Facilitate proper positioning out of the expected pattern using pillows, bulky dressings, foam wedges, or orthoses.

Orthoses

Orthoses can be used to facilitate wound healing by immobilizing the wound and protecting key structures in the hand. It is important to note that not all hand burns require orthotic intervention. The decision to use an orthosis or not depends on the depth and extent of the burn and the client’s ability to tolerate positioning, exercise, and function. Most superficial partial thickness burns do not require an orthosis, because healing is completed within 3 weeks. An orthosis should be considered if healing is compromised, or there is a significant limitation in active extension or flexion of hand joints.²⁰ In some cases an orthosis may be indicated for a client who is unable to actively move the hand or for a client who may move too aggressively. Orthoses are used more often with deeper burns. Despite static orthotic intervention in the early phases of wound healing to prevent burn scar contracture, the incidence of contracture has been reported as 5% to 40% with weak evidence supporting their effectiveness.²²

Unless otherwise indicated, immobilize the hand with the wrist in extension, the metacarpophalangeal (MP) joints in flexion, the interphalangeal (IP) joints in extension, and the thumb in abduction. Slight wrist extension encourages MP flexion by means of a tenodesic effect, and MP flexion in turn puts tension on the collateral ligaments to prevent shortening. Proximal interphalangeal (PIP) joint extension protects the vulnerable extensor mechanism, and thumb abduction maintains the first web space. Considerable variation in ideal joint angles can be found in the literature.²³ A consensus calls for wrist extension of 15° to 30°, MP flexion of 50° to 80°, full IP extension or slight flexion, thumb abduction midway between radial and palmar abduction, MP flexion of 10°, and full thumb IP extension (Fig. 34-2).^10,16,20 For isolated burns to the palmar surface, position the wrist in neutral to slight extension, the IP joints in full extension and abduction, and the thumb in radial abduction and extension.²⁰ Never force joints into the ideal position. Although prefabricated orthoses are available, custom orthoses made from perforated material are preferable because they allow a more precise fit and can be adjusted to accommodate changes in edema and joint mobility. Orthoses can be secured by gauze wraps, elastic bandages, or straps.

Precaution. Carefully monitor and adjust how the orthosis is secured to ensure there is no vascular compromise.²⁰

For clients with significant involvement of the IP joints, the surgeon may opt to place Kirschner wires across the joints to obtain complete immobilization and protection of the extensor mechanism.³

Orthoses may also be used in the later phases of recovery to prevent or correct scar contracture. To prevent contracture, use static orthoses, placing joints in positions opposite the direction the scar will pull. Common burn scar contractures in the hand are wrist flexion from volar burns, wrist extension or flexion from dorsal burns, thumb adduction from a burn to the first web space, MP and IP extension from dorsal hand burns, and MP and IP flexion from volar hand burns. Have the client wear the static orthosis at night only, if possible, to avoid compromising functional hand use during the day. Use serial static dynamic orthoses (also known as elastic mobilization) or static progressive orthoses (also known as inelastic mobilization) to regain ROM with joint and/or scar contracture. Place scars under tension in an elongated position to promote new cell growth, collagen remodeling, and tissue lengthening.11,24

Circumferential burns may require alternating use of different orthoses to address all scars.¹⁶

Exercise

Exercise is important in the early phases of burn recovery to control edema, promote tendon gliding, and help maintain ROM and strength. Have the client perform active motion with the dressings removed while you carefully monitor the status of the wound. Muscle pumping exercises with a low number of repetitions can help with edema. Include lumbrical position exercises and adduction/adduction of the fingers to contract intrinsic muscles. If the client is unable to move effectively through full ROM, perform gentle active assistive or passive motion. It is important to stay within wound and pain tolerance; take care to put your hands on the most stable and least painful areas of the wound.

Precaution. Aggressive motion at this stage is harmful to fragile tissue and results in more scarring.²⁰ To prevent tendon rupture, do not perform IP motion if extensor tendon involvement is known or suspected.

In the later phases of recovery, emphasize exercises to achieve full active and passive wrist and hand motion. Include gentle passive exercises for individual joint tightness. Composite wrist and finger flexion or extension exercises may also be needed for scars that cross several joints (commonly seen with dorsal hand burns). Look for the scar to blanch, which indicates it is being effectively stressed.²⁰ Resistive exercises can help with regaining strength and muscle endurance. Stronger muscles are better able to move against tightening scars. Have the client perform resistive exercises in both directions to address scar and tendon adhesions. Use exercises and therapeutic activity to promote strength, dexterity, coordination, and hand function.

Joint mobilization for stiff joints can begin during the scar maturation phase once the scar has adequate tensile strength to tolerate the friction caused by mobilization techniques.

Continuous passive motion (CPM) has been reported to be an effective adjunct to therapy in the treatment of hand burns for clients who show little active motion because of pain, anxiety, or edema.²⁵

Precaution. Be very careful using CPM if extensor tendon injury is involved or suspected, because this technique might be too forceful for the delicate extensor mechanism.

Functional Hand Use

Functional hand use in daily activities should be encouraged as much as possible throughout all phases of recovery. Assistive devices, such as built-up handles, can facilitate functional use if limitations exist. Using the hand has important physical and psychologic benefits; it facilitates motion, strength, endurance, tendon glide, and edema reduction, and it gives the client a sense of self-control and sufficiency. However, keep in mind that improvement in pain, healing, motion, and strength does not always lead to spontaneous reintegration of the hand into tasks. Clients may be fearful of pain or of injuring fragile tissues. Acknowledge these concerns and provide support to help the client overcome them.

Scar Management

The goal of scar management is to modulate scars as much as possible to achieve a flat, smooth, supple, and cosmetically acceptable scar. Because scar formation is an unavoidable component of wound healing, the best we can hope to accomplish is to minimize scarring by altering its physical and mechanical properties through interventions, such as compression, silicone products, massage, and physical agent modalities. The exact mechanisms by which these interventions work are not well understood, and objective support of their efficacy is less than adequate, but they have produced positive clinical effects.26,27

Compression can be provided through a variety of means, including orthoses, compression wraps, and pressure garments. The processes of hypertrophic scarring and scar contraction begin shortly after injury; therefore early application of pressure is advised (that is, within 2 weeks of wound closure).16,20,28 As a rule of thumb, use interim compression bandages and gloves until the hand is ready to be measured for a custom-fitted pressure garment. Pressure from self-adherent elastic wraps is effective in both edema and scar management, and these wraps can be used over light dressings as needed (Fig. 34-3).^16,28 Grade the amount of pressure to make sure it is tolerable. Prefabricated digital sleeves and gloves are an option once the scar is able to tolerate the shear forces created by putting them on, taking them off, and motion while wearing them. Measure for a custom glove only after edema has plateaued, wounds are smaller than a quarter, and the scar is ready to tolerate the heavier pressure and friction custom gloves impose (Fig. 34-4).²⁰ To be most effective, compression devices should be worn continually except during skin hygiene routines and exercise. It may take time for clients to tolerate full-time wear.

Silicone products are available in many forms, including sheets and putty. Some silicone gel sheets are self-adherent, whereas others must be held in place. Silicone can be used alone, but is often combined with pressure although the effectiveness of using both together has been mixed.29,30 Some manufacturers make pressure garments with a thin silicone lining, but these may be more difficult for a client to put on and remove because of increased friction from the silicone. The recommended wearing time for silicone is a minimum of 12 to 24 hours a day; close monitoring is required since its occlusive nature may cause maceration.^16,20

Precaution. Do not apply silicone over open wounds or fragile skin.

Massage, delivered manually or with a vibrator, may be helpful for freeing restrictive fibers, reducing itching, and relieving pain.31,32 Begin with gentle massage of newly healed skin to avoid blister formation and skin breakdown. As tensile strength improves, progress to greater pressure causing scar blanching and massage with circular motions to work the scar in all directions. Lubricate the scar before massage to precondition the tissue. Massage should be performed at least twice a day.^16,20

Physical agent modalities (for example, hot packs, paraffin, fluidotherapy, and ultrasound) have been used for burn scars to precondition tissues for exercise and activity.16,20 Heat can reduce pain and improve elasticity of collagen fibers making the scar easier to mobilize. Paraffin combines the benefits of heat and skin lubrication, both of which are useful before motion. Fluidotherapy can also help with desensitization of hypersensitive scars. Dense burn scars are best heated by ultrasound.

Precaution. Care must be taken with heat modalities, because scars may have diminished sensation and heat tolerance. Never use heat on open wounds or broken skin.