Transcript of "Chapter 4 burn rehabilitation and reconstruction"
CHAPTER-3 Burns: Rehabilitation and ReconstructionIn history, survival was the only gauge of success in managing those withserious burns. More recently, the overriding objective of all aspects of burncare has become reintegration of the patient into his or her home andcommunity. This objective has extended the traditional role of the burn careteam to well beyond completion of acute wound closure. There are 3 broadaspects of this effort: rehabilitation, reconstruction, and reintegration.ACUTE REHABILITATION IN THE CRITICALLY ILL BURNPATIENTTo attain the objective of optimal long-term function, rehabilitation effortsmust commence from the outset of burn care. Physical and occupationaltherapists play an essential role in the acute management of all burn patients,even those who are critically ill and those with large injuries undergoingresuscitation. If a body part is left immobile for a protracted period, capsularcontraction and shortening of tendon and muscle groups that cross the jointsoccur. It is amazing how rapidly this process can occur.Ranging and anti-deformity positioningPassive ranging and anti-deformity positioning in the critically ill patient canprevent this. This is best done twice daily, with the therapist taking all jointsthrough a full range of motion. The therapist must be sensitive to thepatients wounds, the status of extremity perfusion, the state of pain andanxiety, and the security of the patients airway and vascular access devices.It is often useful to medicate patients before therapy sessions to increasetheir efficacy and decrease their discomfort. These procedures are importantbut cannot be effectively or humanely performed if they are associated withundue pain and anxiety. Ranging often can be timed to coincide withdressing changes and wound cleansing, minimizing the need for medication.It is, of course, important that the therapist be aware of the airway andvascular access devices associated with care of the critically ill burn patient.
Morbidity and mortality are associated with unexpected loss of thesedevices. Performing these procedures in coordination with the intensive careunit staff, with full knowledge of the location and function of endotrachealtubes, nasogastric tubes, central venous catheters, arterial catheters, andother monitoring devices, can minimize the risk of their loss. Routineinservicing 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 anti-deformity positioning, and(3) establishing initial contact with the patient and family.Preventing deformitiesProperly performed anti-deformity positioning minimizes shortening oftendons, collateral ligaments, and joint capsules and reduces extremity andfacial edema. Although splints are used less frequently than years ago,several predictable contractures occur in burn patients that can be preventedby a properly performed splinting program. These contractures generally areassociated with the flexed position of comfort, except in the hands.Flexion deformities of the neck can be minimized with thermoplastic necksplints, conformers, and split mattresses. In critically ill patients, positioningthe neck in slight extension is often all that can be done. It is also importantnot to allow ventilator tubing to pull the head such that a contracturedevelops. If proper care is not taken, a rotary contracture can develop,generally with the patient turned toward the ventilator.Preventing contracturesAxillary adduction contractures can be prevented by positioning theshoulders widely abducted with axillary splints, padded hanging troughs ofthermoplastic material, or a variety of support devices mounted to the bed.Elbow flexion contractures are minimized by statically splinting the elbowin extension. These splints can be alternated with flexion splints to facilitateretention of full range of motion. Flexion contractures of the hips and kneesare particularly common in young children but can be prevented by carefulranging and positioning. It is important to prevent these even in infants, as
these contractures can interfere with subsequent ambulation. Pronepositioning, although poorly tolerated by some, can assist in minimizing hipflexion contractures, and knee immobilizers can minimize knee flexioncontractures.The equinus deformity, denoting an extended ankle deformity, is a seriousproblem that can occur even if the ankles are not burned during protractedperiods of bed rest with the ankle in extension. The ankle flexors willshorten and, even in the absence of an overlying burn, disabling contracturescan result. However, they can be prevented with static positioning of theankles in neutral and twice daily ranging. Splints designed for this purposecan cause pressure injury over the metatarsal heads or calcaneus ifimproperly designed.These injuries can be prevented using local padding to distribute pressureaway from the metatarsal heads and by extending the footplate of the splintbeyond the heel and cutting out the area around the calcaneus.At least twice daily inspection of all splints for evidence of poor fit orpressure injury is important. Improperly used splints can cause injury.Regular splint examination and inservicing of the nursing staff minimizessplint-related skin injury. Positioning burned extremities just above the levelof the heart reduces edema and is another important aspect of anti-deformitypositioning.Establishing a relationshipFinally, the burn therapists initial assessment and care of those with seriousburns is the beginning of a long-term relationship. It is rewarding for thetherapist to make sure the patient and his or her family know who thetherapist is and understand the essential role of the therapist in their care.Everyone is grateful for regular communication and updates as to progressmade and problems encountered. This information helps to ensurecompliance with therapy goals. It also fuels the expectation that the patientwill again become active and strong upon recovery.
ACUTE REHABILITATION IN THE RECOVERING BURNPATIENTAs critical illness abates and wounds are progressively closed, the role ofphysical and occupational therapists expands and in many ways becomesmore difficult and challenging. Patients become more aware of what hashappened to them and often are fearful of the therapist and the potentiallyuncomfortable procedures they represent. The principal components of burntherapy that characterize this period include the following: • Continue passive ranging. • Increase active ranging and strengthening. • Minimize edema. • Perform activities of daily living. • Prepare for work, play, or school.This period can be difficult for both the patient and therapist. Long-termfavorable outcomes require hard work during this period. It is important forthe therapist not to push too hard but it is also important for the patient toachieve optimal function. A good program of passive ranging during theperiod of critical illness greatly facilitates successful retention of normalrange during this period. Intra-operative ranging can be useful as well.Patients commonly undergo surgery during this period and, in coordinationwith the operating room team, passive ranging can be performed betweeninduction of anesthesia and preparation of the surgical site. Other maneuversthat increase the tolerance of passive ranging include timing of ranging withmedication for dressing changes, administration of opiates orbenzodiazepines, gentle conversation and encouragement, and an unhurriedapproach to therapy sessions.EdemaBurned and grafted extremities commonly have lingering edema that cancontribute to joint stiffness. Reduction of this edema facilitates rehabilitationefforts. The use of custom-fitted elastic garments this early after injury isexpensive because they frequently need to be downsized as edema resolves.Simply wrapping fingers with self-adherent elastic facilitates reduction ofdigital edema. Tubular elastic dressings, elastic wrap dressings, elevation,and retrograde massage also contribute to reduction of extremity edema.
Topical silicone may have a favorable influence on selected evolvinghypertrophic scars.Focus of rehabilitationAs definitive wound closure nears and hospital discharge approaches, thefocus of rehabilitation efforts becomes practical. Activities of daily livingand the impending return to play, school, and work are importantconsiderations in rehabilitation efforts. Resisted range of motion, isometricexercises, active strengthening, and gait training are important objectives.When treating children, it is important to use developmentally appropriateplay to facilitate rehabilitation goals. For example, children with serioushand burns are ideally engaged in play that requires the use of their hands ata motor level consistent with their development.Rehabilitation goalsThe period immediately after discharge from the burn unit is often extremelydifficult for patients and their family. In fact, for many burn patients, thefirst 18 months after discharge is more difficult than the acute stay. Theprincipal rehabilitation goals at this time include the following: • Progressive ranging and strengthening • Evaluation of evolving problem areas • Specific postoperative therapy after reconstructive operations • Scar managementIdeally, the same therapist that worked with the patient during the acuteinpatient hospitalization continues this relationship in the outpatient setting.This both enhances the burn patients experience and helps the therapistdevelop a perspective on the process of burn recovery. If, for reasons ofdistance or managed care, it is not possible to maintain this relationship, itcan be done indirectly through a regular contact between the therapist andpatient at each clinic visit back at the burn unit.Unfortunately, it is not uncommon for range and strength to be lost duringthe first months after discharge. This is particularly true if inadequateprovisions have been made for outpatient rehabilitation or if therapy duringthis important and difficult phase of recovery is turned over to a therapistinexperienced with burn care. The burn unit team should monitor the quality
of outpatient rehabilitation services at the time of routine clinic visits back tothe burn unit. If the patient is loosing substantial range and strength frominadequate therapy, readmission for focused rehabilitation efforts isappropriate.The realities of distance, transportation, and managed care regulations oftenmake it necessary to turn outpatient burn rehabilitation over to lessexperienced therapists. Methods of helping these therapists do a good jobinclude visits to the burn unit prior to discharge, videotaping therapysessions (with the patients written permission), and frequent telephonecontact. Family education and involvement with rehabilitation plans mayfacilitate early identification of evolving problem areas and early institutionof corrective focused rehabilitation efforts.Burn therapists play a central role in planning and performing reconstructiveprocedures in the months and years after acute discharge. They help toidentify needed operations, plan sequencing of operations, and educatepatients and families about peri-operative care. Planning developmentallyappropriate postoperative rehabilitation activities allows the patient tobenefit the most from his or her operation.SCAR MANAGEMENTScar management is an essential aspect of outpatient burn therapy.Hypertrophic scarring, with its poorly understood physiology, is in manyways the burn patients worst enemy . Perhaps the most virulent hypertrophicscarring is seen in deep dermal burns that heal spontaneously in 3 or moreweeks.This seems especially true in areas of highly elastic skin, such as the lowerface, submental triangle, and anterior chest and neck. The wound hyperemiathat is universally seen following burn wound healing should begin toresolve approximately 9 weeks after epithelialization. In wounds destined tobecome hypertrophic, increased neovessel formation occurs with increasingerythema after 9 weeks.Methods to modify scar formationTools available to modify the progression of hypertrophic scar formation areseverely limited both in number and in effectiveness. These interventionsinclude scar massage, compression garments, topical silicone, steroid
injections, and surgery. In selected contractures, serial casting may beuseful, particularly in the management of established scars that limit themotion of major joints.Conscientious scar massage can be quite effective in limited areas ofscarring and can be performed by family members. This is optimally doneseveral times each day as firm, slow massage of evolving hypertrophic areasafter application of bland skin emollients . Moisturizers have the addedbenefit of minimizing the inevitable dryness that accompanies recentlyhealed burns and skin grafts.Compression garments: Although controversy remains over the issue, asignificant weight of opinion and experience supports the contention thatcompression garments facilitate control of broad areas of hypertrophicscarring, particularly in young children in whom this process seems to bemore severe. It is recommended that compression garments be worn 23hours a day until such time as wound erythema begins to abate, usuallyapproximately 12-18 months after injury. Growing young children requirefrequent refitting and replacement. Garment fit must be verified aftermanufacture, as a poorly fitting garment is less effective and can beuncomfortable.Topical silicone: Applied to the healed wound as a sheet, topical silicone hasbeen demonstrated to be effective when applied to small areas oftroublesome hypertrophic scar. Some children develop a rash beneath thetopical silicone, but this quickly resolves with removal. Ideally, the siliconeshould be in place 24 hours a day, except for bathing. However, in thosewho develop a rash beneath the silicone, application 12 hours a day or everyother day seems to help. Silicone sheets can be placed beneath compressiongarments or can be held in place by a number of elastic devices. Firmpressure is not required for the silicone to be effective.Steroid injections: Steroid injection directly into localized early hypertrophicscars, especially if they are in highly cosmetic locations or are causingextreme pruritus, can be useful. It is important to limit the total dose so thatsystemic effects do not occur. These injections are painful, as they requirehigh pressure to infiltrate the dense hypertrophic scars. In children, generalanesthesia usually is required. Only localized symptomatic areas are treatedin this fashion. As discussed below, surgical excision or incision and
autografting is a useful maneuver when routine scar management tools areineffective.Extreme pruritusUnfortunately, extreme pruritus is an all too frequent part of burn woundhealing. This typically begins shortly after the wound is healed, peaks inintensity 4-6 months after injury, and then gradually subsides in mostpatients. It can be very troubling at night. In most patients it is adequatelymanaged with massage, moisturizers, and oral antihistamines at night. Thereare a number of other alternative approaches to this difficult problem,although none work reliably for everyone.In those who are particularly troubled by pruritus, a sequential therapeutictrial of each maneuver often identifies one that is particularly helpful for thatindividual. These include allowing the child to gently scratch overcompression garments, topical vitamin E-containing creams, topicalantihistamine-containing creams, topical cold compresses, frequentapplication of moisturizing creams, or colloidal baths. Localized highlypruritic scars often respond to a steroid injection.On rare occasions, pruritus becomes so intense that excoriations develop.These wounds can become superinfected with Staphylococcus aureus thatfurther exacerbates the pruritus. Some of these children are best admitted forwound care and antibiotics to control the pruritus and facilitate healing ofexcoriated areas. Burn wound pruritus is a difficult, albeit thankfully self-limited, problem that begs for an effective solution.BURN RECONSTRUCTION BASICSProper acute burn care minimizes the need for burn reconstruction.However, even in optimal circumstances, a predictable set of reconstructiveoperations is commonly required during the first post injury years. Areconstructive plan is best made collaboratively with the patient and his orher family, the patients burn therapist, and the surgeon. Although oneshould not rush in to these procedures, the concept of waiting until all scarshave completely matured for more than 2 years prior to embarking onreconstructive operations unnecessarily prolongs recovery.
The physical and emotional trauma of surgery must be balanced against thepatients functional and cosmetic needs. These plans are never easy todevelop and must be carefully considered and individualized. No twopatients are alike; imagination and patience are important components ofplanning staged burn reconstruction.Most burn reconstructive procedures can be performed using a combinationof a few basic techniques: incisional release and grafting, excisional releaseand grafting, Z-plasty, and random flaps. Less commonly needed but usefulin selected patients are tissue expansion and free flaps.Incisional versus excisional releaseMost burn reconstructive operations can be performed with an incisional,excisional, or commonly a combined release, closing the resulting woundwith split-thickness autograft. The contracture is placed under tension andthe release performed sharply. Adjacent areas of hypertrophic scar can beexcised if donor sites are adequate to close the larger wound. Full-thicknessskin grafts are less likely to contract than thin split-thickness grafts, and arethe closure of choice in selected circumstances, such as flexion contracturesof the digits.However, full-thickness graft site availability is generally more limited thansplit-thickness, and thicker split-thickness grafts perform adequately in mostsituations. In those patients with limited donor site availability, thin split-thickness grafts can be placed over acellular allogenic dermis to enhanceresults obtainable with thin split-thickness grafts alone.Z-plasty in burn reconstructionAlthough simple in concept, properly planned and executed Z-plasties arepowerful reconstructive tools. The basic steps involved in constructing a Z-plasty include the following: • Define the line(s) of tension that need to be modified. • Plan the central limb of the Z-plasty(s) on this line • Design the lateral lines, if possible, so that they fall along natural skin lines ("Langer" lines) after transposition.
• Design the angle between the central and lateral lines of the Z-plasty to be less than 90° with the lateral limbs curved and no longer than the central limb.Within these limits, an infinite variety of Z-flaps are possible by modifyingthe basic concept based on blood supply of flaps and local tissue elasticity.A "5 flap Z-plasty" can be constructed by placing two Z-plasties along thesame band, orienting them such that they are mirror images of one another.This results in a fifth "dog ear" flap, which can be inset to insert additionalelastic tissue into the band. Multiple Z-plasties can be used in series along aband to excellent effect. The Z-plasty is limited more by the surgeonsimagination than the elasticity of adjacent available tissues.Tissue expanders and flaps in burn reconstructionLocal flaps, tissue expanders, and free flaps have a more limited butimportant role in burn reconstruction. Thin random flaps can be raised on thechest wall to cover small fourth-degree wounds of the hands in selectedcases, the flap being divided at 3 weeks. More commonly used are groinflaps, which have earned an important role in reconstructing defects,particularly volar wrist defects associated with high voltage electrical injury.Tissue expanders are useful, particularly in the head and neck. Perhaps mostuseful are tissue expanders to correct burn-associated alopecia. Like tissueexpanders, free flaps offer an important option in selected difficult wounds,such as those associated with high-voltage injury and extensive soft tissueloss of the distal lower extremity.BURN RECONSTRUCTION IN THE HEAD AND NECKUsually, few reconstructive procedures are necessary in the face, head, andneck during the initial year after injury if deep facial burns have beenresurfaced in cosmetic units with thick sheet grafts. The two commonexceptions are the ocular adnexa and the neck. The pliant nature of the tissuearound the eyes and mouth, combined with the important functions related totheir normal position, render these areas at extreme risk for early problemsrelated to tissue contraction. Any contracture that may impede access to theairway assumes a high priority in initial reconstruction.Other predictable needs relate to lip eversion, microstomia, thickenednasolabial bands, and obstruction or distortion of the nares that occur with
progressive contraction and thickening, particularly of deep dermal burnsthat heal over a protracted period of time. Perhaps the most mobile structuresof the face are the eyelids. Therefore, it is common for ectropion to occur inthe months following injury. Typically, only the skin and subcutaneoustissue are contracted, rolling the other structures away from the globe. Lidelevation is compromised if muscle is injured, unsightly protrusion ofperiorbital fat occurs if the orbital septum is violated, and coverage of theglobe can be threatened if the tarsal plate is damaged. It is crucial tounderstand this anatomy prior to embarking on lid release; otherwise onemay injure these distorted but normal structures.The skin of the anterior neck is thin and elastic. Full-thickness burns in thisarea ideally are replaced with thick sheet grafts early in the acute course.However, even with the best short-term surgical effort, it is difficult toproduce an optimal long-term result. Even with diligent use of conformersand neck splints, contractures are common with a loss of the normalconcavity between the tip of the chin and the sternum. When this becomesfunctionally important, neck release is indicated. Most patients have asatisfying result with release and split-thickness sheet autografting, althoughlocal flaps and tissue expanders provide additional options in selectedpatients and anatomic circumstances.BURN RECONSTRUCTION OF THE UPPER AND LOWEREXTREMITIESUpper extremityHigh-quality acute burn care minimizes upper extremity reconstructiveneeds; however, problems requiring correction regularly occur. Perhaps themost common upper extremity deformities requiring correction are dorsalhand and web space contractures. Dorsal hand contractures are ideallyprevented by attention to proper positioning during and after surgery. If theinitial excision was tangential rather than fascial, such that some remnantdorsal subcutaneous fat remains, the release will slide and accept a largepiece of skin. It is important that the release result in a resistance-freecomplete range of motion of the metacarpophalangeal joints.Web space contractures can be minimized by proper early surgery andcompressive gloves supplemented with web space conformers. However,
these remain common deformities. In the normal web space, the leadingedge of the volar aspect of the web is distal to the dorsal aspect. In thetypical dorsal web space contracture, this is reversed, with syndactylyusually being a dorsal deformity. When severe, they can limit abduction ofthe digits, thus should be corrected. It is important not to compromise thetypically normal leading palmar edge of the web space.Deep burns of the elbow are commonly associated with difficultymaintaining a complete range of motion. Normal elbow range is required foractivities of daily living, such as feeding and toileting. Limited elbowextension is commonly a volar soft tissue issue that responds nicely tosimple release. However, heterotopic ossification also may contribute andshould be excluded. This occurs when bone forms in the soft tissues aroundthe triceps tendon, interfering with elbow motion. Although it may resolvespontaneously over the course of years, if heterotopic ossification interferessignificantly with recovery it should be managed surgically. It is amechanical problem in which the range of the elbow joint is compromisedwhen components of the joint abut the abnormal bone. A careful dissectionin which the bone is removed such that the elbow joint is not blocked isrequired. It is important to visualize and protect the ulnar nerve during thisdissection.Axillary contracture is not uncommon and can interfere with the ability tofeed and perform other important upper extremity functions. Axillary releaseshould encompass the entire axis of rotation of the shoulder to facilitatecomplete range of motion. The defect is closed with sheet autograft.Postoperatively, it is important that abduction splints maximize range ofmotion without creating traction or pressure on the brachial plexus orvessels.Lower extremityThe most common lower extremity deformities requiring correction in burnpatients are dorsal foot extension contractures, popliteal flexion contractures,and hip flexion contractures. The latter two are particularly common ininfants and young children who spend long periods with the hips and kneesflexed and who are particularly difficult to splint and range.A deep dorsal foot burn may result in a contracture of themetatarsophalangeal joints such that the toes are brought off the ground,
causing the patient to walk with an abnormal gait. When severe, thisinterferes with ambulation and should be addressed surgically. An incisionalrelease will accept a large piece of split-thickness skin, particularly if theinitial operation was performed in a layered fashion leaving viablesubcutaneous fat.Flexion contractures of the popliteal fossa also interfere with ambulation.Correction generally requires incisional release and grafting, with directedpostoperative efforts to maintain knee extension. It is important to avoidinjury to the relatively superficial underlying neurovascular structures of thepopliteal fossa.Flexion contractures at the hips are common in infants and young childrenwho spend little time with the hips in extension. The contracted position ofcomfort is with the hip in flexion. This deformity interferes with ambulationand should be addressed early in the process of recovery. It is important tobe sensitive to the location of the femoral vessels and nerve and avoid injuryto them, particularly as the overlying contracted tissues commonly distortnormal anatomy.REINTEGRATION AND CONCLUSIONSThe ultimate goal of all burn care is reintegration; therefore, it is importantnot to lose sight of this. Burn care does not stop with wound closure. Just afew years ago, the goal of the burn team was survival. It was counted as asuccess if the patient lived to discharge. This is no longer enough. Ideally,the patient should be returned to his or her family, schoolmates, andcommunity as if the injury had never occurred. Having this goal meansrespecting the needs of those attempting to return to work and school whenplanning the timing and type of reconstructive operations. Posttraumaticstress disorder is common in burn patients, and the stress on families isenormous. Look for posttraumatic stress disorder symptoms. Signs includehyper-alertness, nightmares, and chronic fearfulness. Not addressing thiscommon problem compromises recovery.Rehabilitation and reconstruction of the patient with serious burns is part ofacute care. A burn intensive care unit with a separated reconstructive surgerycapability simply cannot generate the quality outcomes for burn patients that
are now possible. As it is now defined, successful burn care requires hardwork by a focused multidisciplinary team over the continuum of care, fromresuscitation through reconstruction, rehabilitation, and reintegration. THE END FIGURE 1. Superficial burns on the trunk and right arm of a young child. Typically, these are red burns that blanch with pressure.
FIGURE 2. Superficial partial-thickness burn on a mans right knee. Blistering woundsthat blanch with pressure are characteristic of superficial partial-thickness burns. Thesewounds are also typically moist and weeping.
FIGURE 3. Deep partial-thickness burns on the trunk and extremities of a young child.These burns are typified by easily unroofed blisters that have a waxy appearance and donot blanch with pressure.
FIGURE 4. Full-thickness burn on a womans left flank. Burn areas of this type arecharacteristically insensate and waxy white or leathery gray in color. **********************************************************
TABLE 1Classification of Burns Based on DepthCharacteristicsClassificationCauseAppearanceSensationHealing timeScarringSuperficial burnUltraviolet light, very short flash(flame exposure)Dry and red; blanches withpressurePainful3 to 6 daysNoneSuperficial partial- thicknessburnScald (spill or splash), short flashBlisters; moist, red and weeping;blanches with pressurePainful to air and temperature7 to 20 daysUnusual; potential pigmentarychangesDeep partial- thickness burnScald (spill), flame, oil, greaseBlisters (easily unroofed); wet orwaxy dry; variable color (patchyto cheesy white to red); does notblanch with pressurePerceptive of pressure onlyMore than 21 daysSevere (hypertrophic) risk ofcontractureFull-thickness burnScald (immersion), flame, steam,oil, grease, chemical, high-voltage electricityWaxy white to leathery gray tocharred and black; dry andinelastic; does not blanch withpressureDeep pressure onlyNever (if the burn affects more
Chart for Estimating Area of BurnsLeft foot18.104.22.168.53.53.5Total: *--
TABLE 2American Burn Associations Grading System for Burn Severity andDisposition of PatientsType of burnMinorModerateMajorCriteria:<10 percentTBSA burn inadult<5 percentTBSA burn inyoung or old<2 percent full-thickness burn10 to 20 percentTBSA burn inadult5 to 10 percentTBSA burn inyoung or old2 to 5 percentfull-thicknessburnHigh-voltageinjurySuspectedinhalation injuryCircumferentialburnConcomitantmedical problempredisposing thepatient toinfection (e.g.,diabetes, sicklecell disease)>20 percentTBSA burn inadult>10 percentTBSA burn inyoung or old>5 percent full-thickness burnHigh-voltageburnKnowninhalation injury
Management of BurnsFIGURE 6. Algorithm for the management of patients with burns.Adapted from Peate WF. Outpatient management of burns. Am Fam Physician 1992;45:1326.