Burns, Rehabilitation and Reconstruction

To attain the objective of optimal long-term function, rehabilitation efforts must commence from the outset of burn care. Physical and occupational therapists play an essential role in the acute management of all burn patients, even those who are critically ill and those with large injuries undergoing resuscitation. If a body part is left immobile for a protracted period, capsular contraction and shortening of tendon and muscle groups that cross the joints occur. It is amazing how rapidly this process can occur (see Image 1).

Ranging and antideformity positioning

Passive ranging and antideformity positioning in the critically ill patient can prevent this. This is best done twice daily, with the therapist taking all joints through a full range of motion. The therapist must be sensitive to the patient's wounds, the status of extremity perfusion, the state of pain and anxiety, and the security of the patient's airway and vascular access devices. It is often useful to medicate patients before therapy sessions to increase their efficacy and decrease their discomfort. These procedures are important but cannot be effectively or humanely performed if they are associated with undue pain and anxiety. Ranging often can be timed to coincide with dressing changes and wound cleansing, minimizing the need for medication.

It is, of course, important that the therapist be aware of the airway and vascular access devices associated with care of the critically ill burn patient. Morbidity and mortality are associated with unexpected loss of these devices. Performing these procedures in coordination with the intensive care unit staff, with full knowledge of the location and function of endotracheal tubes, nasogastric tubes, central venous catheters, arterial catheters, and other monitoring devices, can minimize the risk of their loss. Routine in-service training of therapists facilitates adherence to necessary precautions. The 3 principal priorities for the burn therapist in the acute setting are (1) ranging, (2) splinting and antideformity positioning, and (3) establishing initial contact with the patient and family.

Preventing deformities

Properly performed antideformity positioning minimizes shortening of tendons, collateral ligaments, and joint capsules and reduces extremity and facial edema. Although splints are used less frequently than years ago, several predictable contractures occur in burn patients that can be prevented by a properly performed splinting program. These contractures generally are associated with the flexed position of comfort, except in the hands.

Flexion deformities of the neck can be minimized with thermoplastic neck splints, conformers, and split mattresses. In critically ill patients, positioning the neck in slight extension is often all that can be done. It is also important not to allow ventilator tubing to pull the head such that a contracture develops. If proper care is not taken, a rotary contracture can develop, generally with the patient turned toward the ventilator (see Image 2).

Preventing contractures

Axillary adduction contractures can be prevented by positioning the shoulders widely abducted with axillary splints, padded hanging troughs of thermoplastic material, or a variety of support devices mounted to the bed. Elbow flexion contractures are minimized by statically splinting the elbow in extension. These splints can be alternated with flexion splints to facilitate retention of full range of motion. Flexion contractures of the hips and knees are particularly common in young children but can be prevented by careful ranging and positioning. It is important to prevent these even in infants, as these contractures can interfere with subsequent ambulation. Prone positioning, although poorly tolerated by some, can assist in minimizing hip flexion contractures, and knee immobilizers can minimize knee flexion contractures.

The equinus deformity, denoting an extended ankle deformity, is a serious problem that can occur even if the ankles are not burned during protracted periods of bed rest with the ankle in extension. The ankle flexors will shorten and, even in the absence of an overlying burn, disabling contractures can result. However, they can be prevented with static positioning of the ankles in neutral and twice daily ranging. Splints designed for this purpose can cause pressure injury over the metatarsal heads or calcaneus if improperly designed.

These injuries can be prevented using local padding to distribute pressure away from the metatarsal heads and by extending the footplate of the splint beyond the heel and cutting out the area around the calcaneus.

At least twice daily inspection of all splints for evidence of poor fit or pressure injury is important. Improperly used splints can cause injury. Regular splint examination and inservicing of the nursing staff minimizes splint-related skin injury. Positioning burned extremities just above the level of the heart reduces edema and is another important aspect of antideformity positioning.