Chapter 4 Burns and Plastic Surgery
Introduction
• Early intervention of therapy is imperative for a successful outcome in burns management.
• From admission, splinting, positioning and exercises all become part of the patient’s daily routine.
• The patient and team commitment to treatment and restoration of function is vital in order to achieve good outcomes.
• Careful consideration of the care, rehabilitation and management of multiple problems in this group is needed by a multidisciplinary team.
• A clear insight into the reasoning processes that enable treatment progression and decision making is vital.
• The ultimate goal is to assist the patient to return to their preinjury status, or as near as possible, physically, psychologically and functionally to this.
The burns team
• The team consists of a number of dedicated professionals, who have a variety of roles in the management of a burns patient (Table 4.1).
• The roles of the team will overlap and merge in units around the country; they have been listed above to provide an indication of the variety and diversity of skills needed by each professional.
• For the purposes of this volume, treatment has been divided into pre- and post-healing stages.
Table 4.1 The burns management team
| Surgeons | Psychologist |
| Nurses | Physiotherapist |
| Dietician | Occupational therapist |
| Social worker | |
Pre-healing stage
Acute medical management
• This will include pain management encompassing sedation if necessary, giving humidified oxygen, maybe via continuous positive airways pressure (CPAP) or intermittent positive pressure ventilation (IPPV) to maintain gas exchange, fluid resuscitation, feeding (possibly via nasogastric (NG) tube), dressings, excision and grafting.
Respiratory physiotherapy treatment
• Standard respiratory physiotherapy assessment and treatment techniques apply, but there will be a few key differences.
• The effect of smoke inhalation and thermal injury has been covered in Volume 1 of this book.
• Inhaled smoke will affect the respiratory function of patients.
• They may not initially present with any signs of underlying respiratory damage; however, they can deteriorate rapidly and may need admitting to an Intensive Care Unit at short notice.
• The therapist must be mindful of the patient’s pain levels and especially of the location of the burns when performing manual treatments.
• Graft sites must not be disturbed for at least 5 days postoperatively, to avoid shearing, although respiratory problems will take precedence over the burns as they are more likely to become life-threatening.
Intubation
• This may be necessary, especially if the patient is suffering from facial or neck burns, with accompanying oedema, or poor blood gases.
• Intubation can be by endotracheal tube, or tracheostomy, and can allow mechanical ventilation to be used.
• IPPV is required in patients with respiratory failure, with this being indicated by:
• It is not the aim of this book to cover all respiratory treatments; however, the following treatments may be encountered in addition to ventilation:
Flaps and grafts
• Early excision and grafting is preferable for a number of reasons:
• Skin grafts are used to facilitate healing in deep dermal or full-thickness burns.
• The most commonly used graft is a split-thickness graft (SSG), which contains a variable portion of the dermis.
• Burns are first debrided to a viable capillary bed; the donor skin is harvested and moved to cover burnt areas.
• The donor site will heal in 10–14 days; however, this can be very painful initially.
• A skin graft may be meshed to provide coverage of a greater surface area at the recipient site. The spaces between the meshing allow bacteria and fluid to drain.
• The appearance of the mesh will remain long term, which may influence the choice of graft used in cosmetically sensitive areas.
• Different types of split skin grafts:
• Grafts and flaps over joints need to be immobilised with dressings and splints until the doctors are happy the skin graft has taken.
• At this point therapy can begin to manage the joint range.
Positioning
• This is fundamental for successful burns rehabilitation, in order to minimise chest complications and pressure areas, to enable wound care and healing, to decrease oedema and maintain tissues in an elongated state to prevent contractures.
• The areas of the body most likely to contract are the neck, axillas, elbows, thumb and finger web spaces, knees, ankles.
• If possible the patient should be turned regularly in the bed, and nursed on a pressure care mattress.
• Once they are out of the acute phase, they should be encouraged to sit out of bed for periods during the day.
• Patients with burns to the anterior neck should be nursed without pillows to prevent early contractures developing.
• Oedema will develop within a few hours of the burn injury and peaks at approximately 36 hours; therefore, consider elevation of the extremities, using foam slings, wedges or pillows.
• Positioning may be maintained with suitable splints, e.g. resting splints for the hands in a POSI, or foot-drop splints for the feet, which can be applied between treatments, or overnight only.
Positioning of the upper limbs
• Axilla burns, anterior chest, and lateral posterior trunk burns are prone to developing contractures preventing shoulder abduction and flexion (elevation), therefore the shoulders must be positioned and stretched into these positions.
• Burns to the antecubital fossa lead to elbow contractures, especially as a flexed elbow tends to be a position of comfort for the patient to rest in.
• Elbow extension splints may be required at night, including the positioning of the forearm into supination.
• Elevation of the hands in Bradford slings designed to assist swelling control. If the shoulders do not permit this, then the hands should at least be elevated on pillows.
Positioning of the lower limbs
• Hips need to be positioned in neutral rotation and slight abduction using foam wedges, towel rolls or sandbags.
• Prone lying is an excellent position to stretch tight hip flexors, if the burns permit it and the patient can tolerate it for short periods.
• Knees should be positioned in extension when the patient is in the bed, avoiding use of a pillow under the knees, which would encourage flexion contractures.
• Plantar flexion contractures of the foot are the most common encountered, so the ankle should be placed in a neutral position, unless the burn is isolated across the anterior surface of the ankle and foot.
• This can be achieved with the use of splints, pillows, or foam.
Musculoskeletal treatment
• The aim is to maintain range of movement, especially over joints in the hands, which will contract quickly, if not stretched regularly.
• If the patient is conscious, it is important to encourage active movements.
• If the patient is not conscious then passive stretches will be necessary.
• It is essential to avoid being too aggressive or vigorous as this can rupture fine muscle fibres and vessels surrounding the joint, producing a haematoma within the joint space, which may eventually lead to fibrosis or heterotopic calcification (Richard and Staley 1994).
• Passive movements should be slow, gentle and controlled, aiming to achieve full range of movement.
• Donor sites can be moved and they will feel sore, but there are no restrictions to movement of this area.
• However, joints in close proximity to newly grafted sites must not be moved until the surgeon has agreed the graft has taken.
• This will be approximately 5 or more days post graft application.
• If a surgeon feels the graft has not ‘taken’ they may instruct the therapist to move the joint, until further surgical management can take place.
• Care is needed to avoid stressing areas of deep tissue damage, such as exposed tendons or joints.
• Respect the patient’s wishes and their tolerance of pain, although ultimately it is essential to treat in order to avoid long-term contractures.
• Patients tire easily during treatment, partly due to the increased energy expenditure that accompanies the loss of the skin barrier.
• They may lose up to 10% of their body weight during the post-injury period, despite careful monitoring of their calorie intake and nutrition.
• Therefore, careful consideration of the frequency and timing of treatments is important and liaison with the nursing and medical staff is essential to avoid clashes of treatment.
• Individual hospital policy or staffing may dictate whether the patient receives 5, 6 or 7 days of treatment in a week.
• Treatment may be carried out whilst the patient’s dressings are in situ, although it is vital to view the burns during their healing phase, in order to facilitate good handling by the therapist and to predict areas of possible contractures.
• Assisting the nurses during dressing changes can be helpful, although once the dressings are in place they can help to cushion the therapist’s hands and spread the pressure applied during the manual treatment.
• There is a high risk of infection due to the loss of the skin barrier, so use of infection control techniques is even more fundamental in the burns patient than usual.
• Liaising with the patient’s relatives/carers is crucial, and they may be keen to be involved in their relative’s rehabilitation, perhaps performing correctly taught passive movements between therapy sessions.
• The family should be educated regarding the aims and all other aspects of the therapy programme, including the benefits of treatment and the risks of non-compliance (Leveridge 1991).
• The advice may include some of the common adages relating to burns (Box 4.1).
Box 4.1 Common adages for the management of burns
• ‘Mornings are always the worst due to stiffness from inactivity during the night’
• ‘Burn scar contracture is a lack of tissue to go around’
• ‘Stretch opposite the burn, e.g. elbow extension if the burn is in the antecubital fossa’
• ‘The sum of the parts does not always equal the whole’ (i.e. may need to stretch multiple joints at a time)
• ‘If it’s white, it’s tight and needs to be stretched’
• ‘Pinching pain (to be avoided) or stretching pain (to be expected)’
Mobility
• As soon as the patient is medically stable and coming out of the acute phase, consideration of their mobility must be of prime importance.
• Transferring out of bed into a chair or wheelchair, followed by gait assessment and re-education can be carried out by the therapy team. This will include the provision of appropriate aids, seating and advice.
• If the patient has been in bed for a prolonged period of time, they may need to be treated on a tilt table initially to enable them to be brought gradually up into an upright posture.
• Likewise the gradual introduction of lower limb dependence (‘dangling’) may be required before the patient can tolerate weight-bearing on their legs.
• In the presence of grafts on the legs, the dressings must be covered with double Tubigrip when mobilising.
• If they have stairs at home, they must ascend and descend a flight of stairs prior to their discharge to ensure safety and independence.
Hand burns
• Initial elevation in a Bradford sling is vital to assist the reduction of oedema.
• The hand may be dressed, or may be enclosed in a Flamazine bag, which will be changed daily.
• The most common posture of an untreated burnt hand is with the MCP joints in extension, the IP joints of the fingers in flexion, and the thumb in adduction.
• This can be corrected with the use of thermoplastic splinting in the ‘intrinsic plus’ position, or position of safe immobilisation (POSI) between therapy treatments (wrist at 30–40°, MCPJs at 45–70°, IPJs in neutral and the thumb abducted), to maintain the length of the collateral ligaments and volar plates.
• The splint can be fabricated over the Flamazine bag or dressings, and adjusted regularly as required to ensure a good fit and therefore effective positioning of the joints.
• Active exercises can begin from day 1 post-admission if the patient is conscious and able to comply.
• If not, or if the amount of active movement is poor, passive movements are essential to maintain joint range and muscle length, as well as preventing contractures.
• The exercises are best carried out soon after analgesia has been administered, and preferably without the dressings in situ.
• Passive flexion should be avoided if there is damage to the extensor apparatus of the fingers, otherwise exercises should consist of taking all affected joints through their full range of movement, or as near as the patient can tolerate if they are in pain.
Post-healing stage
• Once the patient is discharged from hospital they will need to continue their care as an outpatient.
• This will probably take the form of hospital outpatient visits, in which they will be seen by a number of team members.
• Dressings will generally be managed by the nursing team.
• Monitoring of healing will be carried out regularly by the surgeons, with the planning of future surgery, if necessary for any further grafting on unhealed areas, scar revision or contracture release.
• The patient will need provision of a tailored home exercise and stretching programme and this will need regular reviews and the addition of appropriate progression.
• Range of movement should be recorded at each therapy session using a goniometer.
• Graded muscle-strengthening exercises involving exercise bands, weights and springs can increase muscle strength, whilst aerobic exercise, such as using an exercise bike, will improve endurance and stamina.
• The patient should be setting goals in conjunction with the therapist, in order to keep motivation levels high, and to ensure that there is tangible progress to measure.
• The community team may be able to help with nursing or therapy provision for those patients who are unable to travel back to the burns unit on a regular basis.
• These health professionals will need to liaise closely with the hospital team, especially if additional information or technical skills are required.
• Aids or adaptations may be required in order to promote self-care activities once the patient has been discharged.
• Splints for positioning and stretching are likely to be an ongoing necessity, so regular appointments will be required to ensure correct fit and continuing effectiveness.
• Family members are often keen to offer support, so it may be useful to compile a list of activities the patient can manage independently and those with which he or she requires assistance.
• Patients may need assistance from members of the therapy team with tasks such as filling in disability claim forms or advice about driving and the questionnaires associated with this.
Scars and healing
• Often a scar settles within 2–6 months, to become white and appears as a fine line. However, scars can become keloid or hypertrophic.
• Keloid scarring is scar tissue which goes beyond the original parameters of the wound, and expands into the surrounding tissue.
• It is often bulky and can be shiny, or red and painful to the touch.
• The type of scar formed after a burn will depend on the depth, type and location of the burn on the body.
• It is very difficult to predict, unless the patient has previous scars which have become keloid, although it is most common in people with Afro-Caribbean heritage.
• Certain areas will be more prone to hypertrophic scarring, e.g. over the sternum, deltoid and the ear (O’Brien 2008).
• Generally it seems that if the burn is healed within 3 weeks the scarring will be minimal, but if this takes longer than 3 weeks the scar is likely to be significant and will probably require some form of treatment.
• Hypertrophic scars are raised, itchy, lumpy, red and painful, and typically develop a few months after the burn, once the site has epithelialised.
• Scars can be seen to get worse within the first 3–6 months before they improve, which needs to be communicated to the patient, so they are forewarned and do not become dispirited by what seems to be a deterioration of their situation.
• Keloid scars extend beyond the original site of the injury and can stay active for several years.
• Contributing factors to hypertrophic scarring include: age, location of the scar, depth of the burn, skin tension and race.
• These types of scars are prevalent in 70–80% of all scars following burns.
• The aims of scar management are to prevent or reduce functional limitation, reduce pain and irritation and to gain an optimal appearance.
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