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Burns and Splinting

An introduction to burns and splinting for Occupational Therapy students.
by

Lucy Fearon

on 13 June 2013

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Transcript of Burns and Splinting

An Introduction
for Occupational
Therapy
Students Burns and Splinting The Skin and Burns Contents To fully understand burns, it is important to understand the anatomy and physiology of the skin.

The skin is the largest organ in the body. Its main functions are:
Protection
Excretion
Prevent dehydration
Support and shape
Regulate temperature

The skin consists of two main parts, the inner DERMIS and the outer EPIDERMIS.

Burns are categorised relating to their depth, and how deep into the skin layers the injury extends. Superficial Burns
(1st Degree) Least severe type of burn.
This classification of burn affects only the epidermis.
The wound is dry and does not blister.
Usually treated at home and do not normally require medical attention, will typically heal within 3-7 days with no scarring. Partial Thickness - Superficial versus Deep
(2nd Degree) Impact of Burns Contracture Burns Overview Effect of burns Splinting Full Thickness Burns
(3rd Degree) Splinting Destroys epidermal layer and extends into dermal layer.
Superficial partial thickness - extends into superficial (papillary) dermis.
Deep partial thickness - extends into deep (reticular) dermis
Some portion of dermis remains which allows wound to regenerate skin cells.
Wound will leak body fluid and is moist to touch.
Generally heal within 7-20 days if properly managed.
Usually leaves a scar which can range from pigment changes to hypertrophy. When? How? Why? Destroys entire epidermal and dermal layers of skin and extends into subcutaneous fat.
Due to level of damage will not heal spontaneously.
Due to nerve endings being destroyed wound is initially painless but is sensitive to deep pressure
Wound will leave a residual scar and is at severe risk of contracture formation. Mature burn scars do not have the capacity to stretch that is found in normal skin. Immature burn scars have a greater capacity to stretch but are prone to the development of contracture deformities.
Prevention of burn scar contracture through exercise, positioning, and splinting is important until the burn scar is mature. (Atchison and Dirette, 2012) It is important to follow up with the patient on a routine basis after discharge to identify and initiate early intervention if significant hypertrophic scar formation and contracture deformities are detected that are impacting the patient’s occupational performance. (Atchison and Dirette, 2012) A burn injury has far-reaching consequences that continue even after the wound is healed.

The impact of a burn injury on an individual’s occupational performance is influenced by the size, location, and depth of the burn injury.

A burn injury may impact an individual’s ability to perform basic ADLs, work or leisure activities.

Burn injuries that have the greatest potential to impact occupational performance include:
deep partial-thickness or full-thickness burns
burns involving major joints
larger burn injuries. Burn scar contracture is the shortening and tightening of the burn scar. Burn scar
contracture deformities are most problematic over large joints. They can severely limit ROM and interfere with the ability to perform ADLs. Incidence of scar contracture in patients with burns ranges from 5% to 40% (Schouten et al, 2011) The occupational therapist (OT) is an integral part of a multidisciplinary burn team. The OT will be involved from the time of admission to the hospital to assess and treat impairment to body structures and function (e.g., contractures and scarring), as well as facilitating clients’ ability to participate in meaningful occupation throughout their recovery to scar maturation and beyond. (Simons, 2009) Appropriate splinting and positioning, whereby tissues are maintained in an
elongated state, are fundamental to the prevention of contractures following burn injury (Spires et al., 2007) . Contractures result from factors such as limb positioning and duration of immobilization. Contractures place the person with a burn injury at risk of functional deficits (Schneider et al., 2006) Splinting of the burned area may be undertaken using a range of media including : foam,
thermoplastics, neoprene (Simons, 2009) . Splinting immediately following skin grafts aims to prevent contracture. Prolonged static splinting is required following skin grafts, but therapy should be started within 2 to 3 weeks with the splint removed for each session.
Six weeks after the surgery, night splinting alone should be sufficient and may need to be continued for 1 or 2 years (Schwarz, 2007) . Joints overlaid by deep partial-thickness or full-thickness burns are at high risk for developing contracture. (Simons, 2009) The shoulder, elbow, and hand are most commonly affected. Upper limb contractures affect ADL's including washing, dressing, grooming and eating. (Schneider et al., 2006) . Splinting is primarily used to prevent or correct contracture deformities
(Schouten, 2012). Positions of comfort often results in contracture formation. By using splints to hold the joints in a static functional position, this will reduce contractures or stop them from forming. (Atchison and Dirette, 2012) (Atchison and Dirette, 2012) Superficial Burn Partial Thickness Burn (Atchison and Dirette, 2012) (Atchison and Dirette, 2012) Full Thickness Burn Generally splints are applied on the surface of the burn to oppose the anticipated deformity. (Jacobs and Austin, 2003) References ATCHISON,B. and DIRETTE, D. (2012). Conditions in occupational therapy: effect on occupational performance. 4th ed., Baltimore, Lippincott Williams and Wilkins.

CURTIN, M., MOLINEUX,M. and SUPYK-MELLSON, J. (2010). Occupational Therapy and Physical Dysfunction. Edinburgh, Elsevier.

DELAVERY, B. et al. (2012). Formation of hypertrophic scars: Evolution and susceptibility. [online]. Journal of Plastic Surgery and Hand Surgery, 46, 95-101. Article from Informa Health Care last accessed 07 June 2013 at http://informahealthcare.com

JACOBS, M. and AUSTIN, N. (2003). Splinting the hand and upper extremity: Principals and Processes. Baltimore, Lippincott, Williams and Wilkins.

KAMOLZ,L. et al. (2009). The treatment of hand burns. [online]. Burns, 35 (3), 327-337. Article from Science Direct last accessed on 05 June 2013 at http://sciencedirect.com

LATENSER, B.A., and KOWAL-VERN, A. (2002). Paediatric burn rehabilitation. [online]. Pediatric Rehabilitation, 5 (1), 3–10. Article from NCBI last accessed 05 June 2013 at http://ncbi.nlm.nih.gov

NHS (2012). Scars. [online]. Article availble at: http://www.nhs.uk/conditions/Scars/Pages/Introduction.aspx last accessed 06/06/2013

SCHNEIDER, J.C. et al. (2006). Contractures in burn injury: defining the problem. [online] . Journal of Burn Care and Research , 27 (4) , 508 – 514. Article from NCBI last accessed 05 June 2013 at http://ncbi.nlm.nih.gov

SCHOUTEN, H.J. et al. (2011). A review on static splinting therapy to prevent burn scar contracture: do clinical and experimental data warrant its clinical application. [online]. Burns, 38, 19-25. Article from Science direct last accessed 03 June 2013 at http://sciencedirect.com

SCHWARZ , R.J. (2007) . Management of postburn contractures of the upper extremity. [online] . Journal of Burn Care and Research, 28 (2) , 212 – 219 . Article from NCBI last accessed 08 June 2013 at http://ncbi.nlm.nih.gov

SHAKESPEARE, P.G. (2001). Standards and quality in burn treatment. [online]. Burns, 27 (8) , 791 – 792 . Article from Science Direct last accessed 06 June 2013 at http://sciencedirect.com

SIMNOS, M. (2009). Splinting: Positioning, edema and scar management due to burn injury. In: SODERBACK, I. (ed.) (2009). International handbook of occupational therapy interventions. New York, Springer.

SPIRES , M.C. , KELLY , B.M. , and PANGILINAN , P.H. , Jr. (2007) . Rehabilitation methods for the burn
injured individual . Physical Medicine and Rehabilitation Clinics North America , 18 (4) , 925 – 948. Article from NCBI last accessed 08 June 2013 at http://ncbi.nlm.nih.gov (Atchison and Dirette, 2012) Burns were traditionally classified as 1st, 2nd or 3rd degree, however since 2001 the main classification system is superficial, superficial partial, superficial deep, or full thickness. (Shakespere, 2001) If wounds are partial or full thickness in depth on a flexor surface of the body the client is at significant risk of long-term functional impairment. (Simons, 2009) (Atchison and Dirette, 2012) Hypertrophic Scars Once the acute phase is over, the splints should be monitored and modified to maintain functionality. The focus is then on rehabilitation and with an emphasis on activities of daily living (Latenser and Kowal-Vern,
2002 ; Simons, 2009) . Acute Phase Rehabilitation Phase The use of splints at night will help to maintain the stretch achieved during the day through ROM exercises. (Atchison and Dirette, 2012) Even with a patient’s best efforts, contracture deformities may develop that will require surgical intervention to release. (Atchison and Dirette, 2012) Positioning The ideal position of the hand for splinting should be:
wrist approx 20-30 degrees extension
MCP flexion approx 80 degrees
IP joints extended
Thumb abducted (Kamolz, 2009) Static, semi-dynamic or dynamic splints can be used to prevent or decrease contracture. (Curtin, Mollineaux and Supyk Mellson, 2010) The formation of hypertrophic scars are a common complication of wound healing (Delavery, 2012) Hypertrophic scars are red raised scars which can form along a wound (NHS, 2012). The formation of hypertrophic scars can lead to contracture. By Lucy Fearon
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