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Innovation and clinical specialities: burns
Burns to the palm of the hand should be treated conservatively
with gentle debridement, as they will often heal spontaneously
because of the depth of the skin. In the paediatric population
contractures may develop, either in the acute phase or, years later,
as the scar growth is less than that of the normal tissue.
For the feet, great care must also be taken with excision of fullthickness
eschar in this area, because the extensor tendons are in
very close proximity to the skin. Autograft skin applied to this area
should be of a narrow mesh to avoid hypertrophic scarring, which
can make it difficult to fit shoes. The toes require the same
considerations as the fingers. 21
Rehabilitation
The goals of the rehabilitation process are to maximize function
and appearance of the scars. This is done by trying to counteract
two main physiologic processes, scar hypertrophy and
contracture.
Hypertrophic Scarring
Hypertrophic scarring generally does not develop in burns that
require less than 2 weeks to heal. Hypertrophic scarring develops
in 33% of wounds that take less than 3 weeks to heal, but 78% of
wounds that take more than 3 weeks. It also affects skin grafts.
Hypertrophic scars are thickened, red, and raised scars which can
often be very itchy. Unlike keloids, hypertrophic scars do not
outgrow their boundaries. They will also generally remodel and
regress over time, but this may take a number of years, and
contractures may develop in the interim. Although children
generally heal quickly, they are at higher risk of hypertrophic
scarring if there is delayed healing. In addition, individuals with
darker skin pigmentation are also at greater risk of hypertrophic
scarring and keloids. Tangential excision and grafting of burns that
require greater than 3 weeks to heal can help prevent or reduce
hypertrophic scarring.
Scar compression is the mainstay of non-surgical hypertrophic
scarring prevention and management. This can be achieved with
customized compression garments, or with elastic tensor
bandages. The goal is to have pressures of approximately
25mmHg. If using tensor bandages, they must be wrapped from
distal to proximal, taking care not to cause ischemia or venous
stasis. Using tensors for compression over grafts should be
initiated after grafts are well healed, approximately 2-3 weeks after
grafting. This should continue until scar maturation, which can
take up to 1-2 years, and is gauged by when the scar is softened
and stabilized.
Scar massage can also help with breaking down of excess scar
tissue. This is often done in combination with stretching exercises
to prevent scar contractures. Scar massage should be done 2-3
times per day with a hypo-allergenic lotion or cream, or petroleum
jelly (Vaseline). Moisturizing and massaging the scars, which can
be dry due to the lack of glands in the scar tissue, may be sore at
first, but usually becomes soothing, and can help with the
itchiness of the scars. Massaging must press hard enough to
blanch the pink scars. Maturation and flattening of the scars can
take 1-2 years, particularly in children where the hypertrophic
phase may be longer. Most scars will eventually fade and lose
their pink colour over time, but the 1-2 year time frame may be
longer.
Silicone gel sheets can also be beneficial. The exact mechanism
is unknown, but they appear to help soften the scar. To reap the
benefits, they must be worn for long periods (over 20 hours a day)
to be beneficial. They can be placed under compression
garments, or simply taped on for areas not amenable to
compression. These can be washed daily and reused.
Contractures
Joint contractures are one of the most challenging aspects of burn
management, and are the main source of disability from thermal
burns. Scar contracture is due to activity of the myofibroblasts
which act to contract scars. When the scars are across joints,
particularly flexion joints, these can lead to permanent flexion
deformities. In addition, flexed positions are often positions of
comfort during the acute phase of burn management,
exacerbating the problem. To combat joint contractures,
stretching and splinting is necessary. Stretching and range of
motion exercises should be initiated from the beginning. With initial
edema, movement may be a bit difficult but should be encouraged
with daily exercises.
To combat joint contractures, stretching, careful positioning and
splinting are necessary. Necks should be hyperextended with a roll
under the shoulders. Axillae should be carefully positioned. Upper
thigh/lower abdominal burns require positioning to prevent flexion
of the hips. Stretching and range of motion exercises should be
initiated from the beginning. With initial edema, movement may be
a bit difficult, but should be encouraged with daily exercises.
Splinting
Contractures are the most debilitating residual stigma of burns,
and high-risk patients (deeper burns over flexion joint surfaces)
can easily be identified. Contractures are much easier to prevent
than to fix. Once developed, can be very difficult to manage and
correct. Elevation of the burned limb reduces edema and
facilitates early joint mobilization. Where surgical treatment is
limited by resource issues; hyperalimentation, good dressings,
splinting and aggressive stretching can still make a big difference
to patient outcomes. Equally, surgical results will improve
dramatically with good post-operative splinting and early
mobilization as soon as the grafts are solid.
Splinting should be considered when any loss of extension is
noted across elbows and knees. Hands should be splinted from
the onset. 51 Simple plaster slabs covered in elastic tube bandage
or “stockinet” make excellent volar hand splints, can be wrapped
on with tensor bandages and are re-usable till soiled. Splints are
often applied overnight, allowing for mobilization and function in
the daytime.
There are numerous splinting techniques suggested. Both static
and dynamic splints can be used. Dynamic splints may be better
for reversing any contractures, as they may gain extension, not
only maintain the gains during therapy. However, they are
significantly more costly to produce, and long-term gains have not
consistently been shown. Many local materials have been used to
produce inexpensive splints, including easily malleable aluminum
sheets.
Neck collar braces, or custom thermoplastic splints may be
used to prevent flexion contractures, and stretches should include
both extension and lateral flexion. The splint should be properly
padded to prevent pressure points. There are also alternative
splinting techniques for the neck 52 . Axilla contractures can be
Hospital and Healthcare Innovation Book 2009/2010 63