Amputations as a result of thermal or electrical burns present a unique challenge that requires a coordinated effort by the rehabilitation team. Complications of surface and deep tissue injury require adjustment to the more standard approaches to prosthetic provision. Accommodations for the complications of joint contracture, skin adhesions, sensation compromise, skin grafts, and muscle flaps must be made by the treating clinicians. Differences in the treatment timelines, socket designs, material options, and component choices are discussed to familiarize the team for optimization of function in this difficult treatment scenario.
Many amputations are sustained as a result of trauma and the associated complications. When burns are the cause of amputation, the difficulty of the rehabilitation significantly increases. Often the burn-related amputation will maintain the presence of tissue and bone characteristics that complicate the fitting of a prosthetic device. These characteristics often include grafted skin, creative muscle flaps to attain surface coverage, skin adhesions, and continuous tissue breakdown. Because of the difficulty of these cases, this specific population may experience the most measurable benefit from a multidisciplinary approach to upper and lower extremity amputee rehabilitation. The most successful rehabilitation outcome will occur when the team has a collective understanding of burn tissue dynamics and healing progression and access to the available prosthetic technology. Most patients with burn amputations can still experience successful prosthetic use, particularly if they have only single amputations of the lower limb. Team members should be able to draw from past experiences and realize that each patient may require unique new or varying prosthetic design adaptations. Communication from each team member will play a crucial role in the progression of the patient’s overall functional abilities.
In addition, burn-related amputations are often combined with other associated injuries that contribute to the complicated polytrauma nature of the care. Also important to remember is that most cases seen by the Department of Defense will eventually require care and services from the Department of Veterans Affairs or private sector. Amputees with compromised burn tissue may not always have easy access to this care. Even today, access to appropriate prosthetic care and associated ongoing or necessary rehabilitation services may be challenging in some areas of the country. Given this scenario, patients should be taught to self-advocate for their care and be educated on socket design, interfaces, componentry, and associated technology. Having this knowledge will help them to successfully identify and communicate issues to their future care providers.
Pre-prosthetic evaluation and training
Electrical Versus Thermal Mechanisms
Severe thermal and electrical burns can result in amputations with similar characteristics, even though the mechanism of injury is different. Electrical and thermal burn injuries may present with several key differences ( Fig. 1 ). Electrical burns from high-voltage contact are associated with longer hospital stays and more complex surgical procedures. Electrical injuries treated with an early faciotomy have an increased incidence of developing deep venous thrombosis and requiring an amputation. These injuries also have an increased prevalence of deep tissue destruction, nerve damage, severe ischemia, and delayed hemorrhage that may compromise future fittings, particularly in the upper extremity.
If a myoelectric system is desired, nerve compromise not only can cause strength and range of motion issues but also may present with reduced efficiency of the electromyogram signals needed for myoelectric control systems. Furthermore, cognitive/brain issues related to entry or exit of the high voltage electrical injury may be possible. Many cases have bilateral upper extremity involvement from the natural tendency for dual-hand grasping of live electrical wires by individuals working around high voltage. Entry and exit areas of high-voltage electrocution injuries have an increased potential for lower extremity damage. One retrospective study showed that free-flap coverage performed as a secondary procedure in flame, contact, or fluid burns had a higher success rate, suggesting that timing of the procedure was correlated to the successful outcome. In terms of the decision to amputate, early identification of nonsalvageable limbs has been shown to decrease infections and improve the mortality rate.
Range of Motion Limitations
Range-of-motion limitations often occur because the surface and underlying soft tissues are adherent and lose elasticity; this is especially true in the presence of skin grafts. Range-of-motion deficits are particularly limiting in the upper and lower extremities when they are short of functional range. To reduce their functional effect on performance, some limitations can be compensated for through alignment and with particular prosthetic components. Adherent skin can be limiting in the lower extremity because the protections afforded by skin elasticity are not present in weight-bearing conditions. In the upper extremity, protection over the bony prominences is compromised, as is sensation, which is helpful in proprioceptive feedback. One large prospective study found that 38.7% of 985 burn patients developed at least one contracture at hospital discharge. Amputation was one of the primary predictors of the severity of a contracture.
Sensation Compromise
As expected, sensation is rarely normal in most burn patients. Grafted skin is considerably thinner than normal skin and has reduced underlying soft tissue. This thinned and compromised soft tissue envelope has an increased potential for hypersensitivity. This skin needs adequate time to heal, but some patients may become apprehensive about touching the limb because of hypersensitivity. Burn patients can also develop hyposensitivity and hypersensitivity. Hypersensitivity can limit the ability to comfortably don and doff the prosthesis and use compression dressings or the liners often incorporated into the prosthetic design. Some patients who present with hypersensitivity of the limb may also have zones of decreased sensation or hyposensitivity. This occurrence can become a problem for patients who are familiar with issues surrounding a hypersensitive part of the limb but are unaware of an area of hyposensitivity, because this can lead to the unknowing development of a skin breakdown secondary to contributors, such as sleeping pressures or compression garments. This hyposensitivity can eventually result in lack of protection from the dangers of friction and pressure within the prosthesis.
The level of sensation present and how it can be interpreted can be determined with simple monofilament sensation mapping. Although the Semmes-Weinstein monofilaments are designed for the plantar surface of the foot, they can be helpful in establishing relative levels of sensation ( Fig. 2 ), which can be particularly helpful when eliciting feedback on the comfort of the prosthesis. If the clinician and patient know where the sensation is reliable, the feedback will be much more consistent and valuable. When patients can tangibly see how limited their sensation is, they are more inclined to take precautions to prevent fitting problems in the limb that can lead to skin breakdown.
Patient goals
Desensitization
Early association of the patient with the amputation is an important step in the desensitization process. Many patients develop an early tendency to avoid contact and even viewing their amputations, which may increase the potential for hypersensitivity and create challenges to comfortable interfacing with the initial prosthetic system. Burn patients may also have an increased potential for limb avoidance because of the nature of the injury and valid levels of pain associated with the extended healing process. Progressive use of ace wraps, residual limb shrinkers, or gel roll-on liners can aid in the desensitization process and help patients interact with their new amputation early and directly. The independent donning and doffing of shrinkers and liners can be great initial exposure to the future world of daily prosthetic use.
Simple limb manipulation and massage should also be implemented early. The discomfort associated with the early limb desensitization process can be eased through performing manipulation over and through the compression garment or liner. This process also prevents interference with the various wound care techniques, such as medications and dressings, that are being implemented on the skin. Occasionally, custom-designed silicon interfacing has been required even at the preprosthetic early stage of treatment because of the shape, range of motion, and state of skin integrity of the burned residual limb. The custom interfaces can be molded, fabricated, and fit on site to expedite the process and maintain the treatment progression for the patient ( Fig. 3 ).
Education and Goal Setting
Even in the very early healing phase of rehabilitation, many patients express their desire for the most advanced prosthetic system possible. It is important for clinicians to help them understand that the initial prosthesis may either have advanced technology or be a more simple design, and often is some combination of both. The patient must trust the prosthetist and the treating team to understand the reasoning behind the component choices. Building early rapport with the patient and family gives them the confidence that the treatment team can be trusted to keep the patient’s best interest at the center of the prescription development for the first limb. The prosthetic options seem limitless and confusing at first, and may be complicated by misinformation obtained from Web searches, personal anecdotes, and well-meaning testimonials. However, the prosthetist and treating team members must also be empathetic and listen to the opinions, desires, and goals of the patient from day one.
Family and Peer Influences
During this early phase of treatment, it is beneficial for the patient and family to begin understanding various aspects of the fit and function of the initial prosthetic system that may be used. Several sessions may be recommended to gradually introduce the patient to current technology options and the concepts behind the progression of prosthetic care within the first 9 to 12 months of treatment. With burn amputees, the family, involved friends, and caregivers must be encouraged to actively participate in the early prosthetic education to help clarify their role in the rehabilitation process. By this time, many family and friends have supported these patients with 24-hour care, and this commitment is a significant one. Family members can be educated on all aspects of the patient’s rehabilitation, including simple things from use of dressings under shrinkers and liners, donning of the prostheses, skin checks, and function of a myoelectric prosthesis, among a variety of other related aspects of prosthetic use and rehabilitation.
A difficult new and unexpected challenge becomes apparent when the patient discharges to an outpatient setting. Without professional 24-hour acute care, patients and family must learn how to gradually rely less on others and increase personal independence. Because each patient will react differently, an understanding of that patient’s cultural view of disability, severity of injury, location of family, and even the circumstance of the injury must be well understood. Family dynamics are different for each case, therefore a family meeting to discuss the rehabilitation goals and plan of progression for use and eventual independence can be very helpful for all parties involved.
Unlike amputations that are secondary to disease processes, traumatic amputations are unplanned, and leave patients little or no time to process the situation. Amputations that are burn-related are often performed in emergent circumstances, and these patients are suddenly introduced, through no choice of their own, to the world of amputation and prosthetic devices. They often feel very isolated and like no one could possibly understand their circumstances. One helpful approach is to introduce these patients to someone who has at least a similar amputation level and has completed rehabilitation. This introduction can provide patients an opportunity to talk with someone with whom they can relate and see firsthand the successful outcomes of rehabilitation. Several organizations can help provide trained peer counselors who are prepared to assist in the transition to or preparing for the first prosthesis.
Medical Justification
In addition to the normal preprosthetic goals and education, preparation for medical justification can begin as early as the day of injury. Education on medical justification includes all treatment providers involved with care of the patient. Experiences and findings of each team member can provide valuable information when formulating a thorough and appropriate medical justification, not only for the initial prosthesis but also those that will follow soon after. Many insurance carriers require that a typical upper-extremity amputee first use standard conventional systems before a myoelectric or hybrid system. The main reasons for this are related to cost and the understanding that in the past many upper-extremity amputees discontinue use of their first prosthesis. Burn amputees may require more advanced upper extremity myoelectric technology earlier than some insurance carriers are accustomed to considering. The more clinical information coupled with published evidence that can be provided to the insurance carrier, the more likely the recommended and prescribed prosthesis will be covered.
Patient goals
Desensitization
Early association of the patient with the amputation is an important step in the desensitization process. Many patients develop an early tendency to avoid contact and even viewing their amputations, which may increase the potential for hypersensitivity and create challenges to comfortable interfacing with the initial prosthetic system. Burn patients may also have an increased potential for limb avoidance because of the nature of the injury and valid levels of pain associated with the extended healing process. Progressive use of ace wraps, residual limb shrinkers, or gel roll-on liners can aid in the desensitization process and help patients interact with their new amputation early and directly. The independent donning and doffing of shrinkers and liners can be great initial exposure to the future world of daily prosthetic use.
Simple limb manipulation and massage should also be implemented early. The discomfort associated with the early limb desensitization process can be eased through performing manipulation over and through the compression garment or liner. This process also prevents interference with the various wound care techniques, such as medications and dressings, that are being implemented on the skin. Occasionally, custom-designed silicon interfacing has been required even at the preprosthetic early stage of treatment because of the shape, range of motion, and state of skin integrity of the burned residual limb. The custom interfaces can be molded, fabricated, and fit on site to expedite the process and maintain the treatment progression for the patient ( Fig. 3 ).
Education and Goal Setting
Even in the very early healing phase of rehabilitation, many patients express their desire for the most advanced prosthetic system possible. It is important for clinicians to help them understand that the initial prosthesis may either have advanced technology or be a more simple design, and often is some combination of both. The patient must trust the prosthetist and the treating team to understand the reasoning behind the component choices. Building early rapport with the patient and family gives them the confidence that the treatment team can be trusted to keep the patient’s best interest at the center of the prescription development for the first limb. The prosthetic options seem limitless and confusing at first, and may be complicated by misinformation obtained from Web searches, personal anecdotes, and well-meaning testimonials. However, the prosthetist and treating team members must also be empathetic and listen to the opinions, desires, and goals of the patient from day one.
Family and Peer Influences
During this early phase of treatment, it is beneficial for the patient and family to begin understanding various aspects of the fit and function of the initial prosthetic system that may be used. Several sessions may be recommended to gradually introduce the patient to current technology options and the concepts behind the progression of prosthetic care within the first 9 to 12 months of treatment. With burn amputees, the family, involved friends, and caregivers must be encouraged to actively participate in the early prosthetic education to help clarify their role in the rehabilitation process. By this time, many family and friends have supported these patients with 24-hour care, and this commitment is a significant one. Family members can be educated on all aspects of the patient’s rehabilitation, including simple things from use of dressings under shrinkers and liners, donning of the prostheses, skin checks, and function of a myoelectric prosthesis, among a variety of other related aspects of prosthetic use and rehabilitation.
A difficult new and unexpected challenge becomes apparent when the patient discharges to an outpatient setting. Without professional 24-hour acute care, patients and family must learn how to gradually rely less on others and increase personal independence. Because each patient will react differently, an understanding of that patient’s cultural view of disability, severity of injury, location of family, and even the circumstance of the injury must be well understood. Family dynamics are different for each case, therefore a family meeting to discuss the rehabilitation goals and plan of progression for use and eventual independence can be very helpful for all parties involved.
Unlike amputations that are secondary to disease processes, traumatic amputations are unplanned, and leave patients little or no time to process the situation. Amputations that are burn-related are often performed in emergent circumstances, and these patients are suddenly introduced, through no choice of their own, to the world of amputation and prosthetic devices. They often feel very isolated and like no one could possibly understand their circumstances. One helpful approach is to introduce these patients to someone who has at least a similar amputation level and has completed rehabilitation. This introduction can provide patients an opportunity to talk with someone with whom they can relate and see firsthand the successful outcomes of rehabilitation. Several organizations can help provide trained peer counselors who are prepared to assist in the transition to or preparing for the first prosthesis.
Medical Justification
In addition to the normal preprosthetic goals and education, preparation for medical justification can begin as early as the day of injury. Education on medical justification includes all treatment providers involved with care of the patient. Experiences and findings of each team member can provide valuable information when formulating a thorough and appropriate medical justification, not only for the initial prosthesis but also those that will follow soon after. Many insurance carriers require that a typical upper-extremity amputee first use standard conventional systems before a myoelectric or hybrid system. The main reasons for this are related to cost and the understanding that in the past many upper-extremity amputees discontinue use of their first prosthesis. Burn amputees may require more advanced upper extremity myoelectric technology earlier than some insurance carriers are accustomed to considering. The more clinical information coupled with published evidence that can be provided to the insurance carrier, the more likely the recommended and prescribed prosthesis will be covered.
Prosthetic prescription: approach and progression
Successful progression of the rehabilitation plan can depend on the appropriateness of the first prosthetic prescription. Prescriptions that are developed systematically to address specific patient characteristics will provide patients the best opportunity to progress with the rehabilitation team. Skin issues are the most common characteristic that need special attention. All prosthetic devices will have some amount of movement, because the prosthesis is used in a functional range of motion. This movement will have both shear and slip associated with it, and may at some point cause skin breakdown. Careful distribution of socket pressure in load-tolerant areas will help maintain skin integrity. Sustained forces through an area with minimal soft tissue coverage or adhesion of tissue to underlying bony anatomy can incur skin breakdown fairly rapidly. Given the compromise in protective sensation for most patients, they can be unaware of the presence of pressure or shear that can lead to breakdown.
In all prosthetic fittings, a well-planned progressive wearing schedule is vital to minimizing complications with skin and load/force-tolerance issues. The wearing schedule protocol requirements must be followed even more stringently than in the population with uncompromised skin. The patient, family, and caregivers must understand that even with the a well-designed and properly fitting prosthesis, early fittings over burned and grafted residual limb tissue will normally have incidence of breakdown and complications. This breakdown can be caused even just from the donning and doffing of the limb. Using lubricants on areas where shear is expected is a simple method to reduce this risk ( Fig. 4 ). These incidences of breakdown can be considered normal and expected as the skin heals, matures, and changes in its structure and quality.
The early fitting process can be delayed too long when waiting for ideal skin before proceeding with fitting of the initial prosthesis. Studies have retrospectively shown that the duration of preprosthetic fitting time can significantly affect the satisfaction and daily use time of the prosthesis. Therefore, efforts should be made to accelerate the process when possible ( Fig. 5 ). This concept can be difficult for many on the treatment team to understand and be comfortable with, although this does not mean that a skin issue that is getting larger, deeper, or showing signs of infection should be tolerated or ignored by the patient or treatment team. In the authors’ experience, educating the patient, therapists, and physicians on why a particular skin complication has developed and how it can be controlled, enables therapy to be cautiously resumed under strict supervision by all providers. However, occasions will still arise that require patients to limit or completely stop the use of a prosthesis because of more significant skin complications, postoperative healing issues, or even pending surgical procedures. At this point the patient should be informed about the reasoning for stoppage and the potential timeline that may be expected before prosthetic adjustment or refitting can occur. Again this shows how critical it is to have a well-developed professional relationship between all caregivers involved.
