2. 1-The skin covers the hand is relatively minor portion of total body surface
area (TBSA=5%).
2-The skin on the dorsal surface of hand is thin, elastic, more flexible,.
While palmar skin is thick, inelastic, and inflexible
3-Palmar skin characterized by alternating thick dermal and epidermal
ridges, and anchored to the underlying fascia by fibrous tracts and fatty
pads, while the dorsal skin has thin dermis that loosely attached to the
underlying tissues this allow free mobility.
3. 4-During burn injuries the hand is exposed part and usually used as reflex
action , with associated flexion this to avoid fair , therefore the dorsal
surface commonly involved , and at same time protecting thick palmar
surface.
5-Hand management dose not mean not only good wound closure but also
return of the hand function.
4. Hand function impairment (anticipated problems)
due to:
• Edema or uncontrolled swelling
• Loss of sensation
• Decreased range of motion
• Loss of digits, or skin .
6. Description
• Hyperextension of MCP jts
• Flexion of interphalangeal jts
• Typically as claw hand but with
different causes
• Flattening of palmer arches
8. • To indentify of contracture grade ,the physical therapist
should put the patient’s wrist in maximum extension to
relax the skin and extensor tendons.
• Then passively flex the MCP jts
9. Type I: if the passive MCP jts flexion is more than 30
degree. The DORSALSCAR is Restriction cause
Type II: if the passive MCP jts flexion is less than 30
degree . the cause of Limitation is dorsal scar and
deeper jt structures
10. Type III
If the MCP jts cant perfom passive flexion .The cause of
this restriction is extensive dorsal scars , fibrosed intrinsic
muscles and subluxed or even dislocated MCP jt
12. Causes of this deformity :
• Thermal injury or tendon ischemia
• Tight scar on the palmer aspect of the hand
• Thumb deformity
perpendicular to
interphalangeal jt
d.t.
thumb
scar runs r band that
MCP jt and dorsal to
13. Description:
• Flexion of proximal inerphalangeal jt
• Hyperextension of distal inerphalangeal jt
• on thumb (flexsion of MCP jt & extension of interphalangeal
14.
15. mallet deformity
Causes : postburn injuries to terminal slip of extensor tendon
extensor tendon compression between base of distal phalnx and
eschar leading to ischemia to terminal slip of extensor tendon
Description : Flexion of distal interphalangeal jt
19. Causes:
1. Scar
2. Dorsal burns that healed by secondary intention
3. Ischemic contracture of intrinsic muscles at MCP jt level
20. Dorsal hooding deformity :
Description:
The patient loss the dorsal digital web space
adduction of thumb toward the index finger with scar
band across the first web space
23. Cupping of palm deformity :
Description: In this deformity the longitudinal and
transverse arches are shaped like cup
Cause : palmer hand burn due to contact thermal
injuries
24.
25. (4) Nail bed deformities
It is a dorsal scarring over DIP with distortion of
eponychial fold, eponychium retraction,
proximal nail exposure. It Limits finger stability with
pinching, fine motor dexterity and
Cosmetically disabling
26. Scar band deformity
1.Adduction of thumb towards index finger with scar
band across the first web space
2.Opposition , pronetion and palmer adduction of
thumb with scar band cross MCP jt of thumb to the
midpalm
27. 3. Redial abduction of thumb with scar band across the
dorsal of thumb proximally to redial styloid process
4. Flexion of MCP jt and IP jt of thumb with scar band
running parallel to MCP jt of thumb
28.
29. Goal Setting for Hand Burn Rehabilitation:
Short-term goal: To maintain and gradually increase the range of
motion (ROM) in the uninjured and injured areas, to reduce edema
and pain, to improve muscle strength and endurance, to prevent
contracture, and to minimize scar formation.
Long-term goal: To improve ROM and muscle strength, to further
enhance exercise capacity, flexibility and coordination, and to
restore the ability of ambulation.
30. Management of hand burn:
1.Edema Control
compressive wraps
elevation
gentle active exercise.
Compressive wraps such as elastic
bandages can be applied directly over the
wound bandages. Each digit and the hand
should be wrapped securely in a
continuous manner, distally to proximally,
using a spiral technique.
31. 2. Positioning
Immobilisation of the hand
Deformity Prevention
The most common deformity
associated with burns is the ‘claw’
deformity
Position of Safe Immobilisation
This position involves: 20-30 wrist
extension, 80-90 degrees flexion MCP
joints, full extension PIP and DIP
joints and palmar abduction of the
thumb
32. Dorsal surface of the hand and finger:
Anticipated deformity: MCP hyperextension and IP flexion and thumb
adduction.
Recommended position: The anti-deformity position of the hand with a
dorsal burn is called (duck bill) or (calm digger) its fundamental
components are: wrist extension -MCP flexion.-IP extension-Thumb palmer
abduction or opposition.
How to maintain this position:
Wrapping a gauze roll or piece of foam into the palm extending through the
thumb web space.
Hand splint.
33. Palmer surface of hand and fingers:
Anticipated deformity: MCP flexion, IP flexion and thumb opposition.
Recommended position: The hand usually is position with all fingers joints
extended and the thumb web space on a slight stretch to preserve finger
extension and thumb radial abduction.
How to maintain this position:
Acute palmer burn by splint.
When burn has been healed a silicon elastomer mitt may provide both
position and pressure support.
37. 4. Scar management
I. Pressure therapy
Pressure therapy can be applied in acute stage to control the
edema if the compartment syndrome is not found. These are
hand specific edema management products such as edema
gloves or digi sleeves.
38. -Exercises are necessary and must be integrated into total program of
burned hand in order to maintain maximum functions.
-The goals of exercises should be directed toward reducing edema,
maintain joint mobility, muscles tone, and promoting functional
independence ,therefore active and active assisted ROM are
recommended.
-The exercises program depend on the extent, depth and location of burn,
as all directly affect the degree of joint limitation and muscles states.
5. Exercise therapy
39. 4-All patients should exercise at least 2-4 times daily.
5-Several short bouts session of 8 to 10 repetition of each exercises are
often more effective than long single session, and decrease frequency, the
later can be used in fibroblastic phase.
6-Exercising during the Hubbard tank session is desirable but not always
possible.
7-Activity of daily living exercises are important types of exercises , as the
main aim of rehabilitation is to return the patient's capacity as maximum ,
and support psychological state of the patients.
8-Forcfull and aggressive passive ROM exercises are unnecessarily.
40. Range of Motion (ROM Exercise):
Emphasis is placed on the movements that oppose the development of
contractures. The choice of exercise should be tailored to the individual needs of
the patient. Active ROM is preferred to passive ROM (PROM); however, if
patients are unable achieve full ROM or participate with maximum effort,
active-assisted movement or passive movement of the hand needs to be
implement.
Frequent exercise, performed multiple times throughout the day, is considered
more beneficial than one intense session. Wound and scar contraction is a
process that is ongoing throughout the day and night and this process needs to
be treated constantly. Repeated ROM is helpful in mobilizing edema and
preconditioning the tissue.
Following tissue preconditioning, splints (static, static-progressive, or
dynamic) or casts can be used to positively influence further gains in scar tissue
length and subsequent ROM.
41. A-Active exercises of hand:
Active exercises of the hand muscles can be used early in the inflammatory phase of
the burn to help in decrease the edema.
If required, aim to take pain relief 20 minutes before exercising.
Aim for at least 10 repetitions of exercise but if you are not achieving good range of
movement the number of repetitions can be increased.
Exercise regularly during the day aiming for full range of movement with maximum 5
to 6 sessions daily.
In the wound healing phase the repetition can be increased with less frequent sessions
pre day .
42. The most frequent exercise is by asking the patient to spinet and pronate
their forearms, flex and extend their wrist, move their hand in small
circles, spread their fingers, flex and extend their fingers, etc.
Flexion of MCP joints maintaining PIP and DIP Joints in extension ,
Flexion of PIP and DIP joints while maintaining MCP joint in extension ,
Abduction and adduction of fingers while maintaining PIP and DIP Joints
in extension
The exercise should be controlled to avoid rupture of the ligaments or
tendons in the following way.
43.
44. B-stretching exercises:
Because there are so many muscles in the hand, it normally
takes at least 30 minutes to an hour to satisfactorily stretch a
patient’s fingers, thumbs, and wrist.
Always stabilize the proximal joint: if stretching the wrist,
stabilize at the forearm, if stretching the thumb, stabilize at the
metacarpal and wrist.
48. C-Gliding of thumb:
Indications
• Ulnar glide to increase flexion
• Radial glide to increase extension
• Dorsal glide to increase abduction
• Volar glide to increase adduction
49.
50. C-Gliding of metacarpophalangeal and interphalangeal joints
Indications :
• Volar glide to increase flexion
• Dorsal glide to increase extension.
• Radial or ulnar glide (depending on finger) to increase extension abduction or
adduction
51.
52. D-Tendon gliding exercises
Tendon-gliding exercises are designed to maintain or develop free
gliding between the FDP and FDS tendons and between the tendons and
bones in the wrist, hand, and fingers.
There are five positions in which the fingers move during tendon-gliding
exercises:
Straight hand (all the joints are extended).
Hook (claw) fist (MCP joints are extended, IP joints are flexed);
Full fist (all the joints are flexed).
Table-top position, also known as the intrinsic plus hand (MCP joints
are flexed, IP joints are extended).
Straight fist (MCP and PIP joints are flexed, IP joints are extended)
53.
54. 6. Continuous passive motion (CPM):-
Recently CPM used for burned patients with following indications;
1-Patients who have extensive burn (large TBSA), involving multiple
joints of the upper extremity,
2-Patients who are unable to participate actively in rehabilitation
program (e.g decrease cognitive function)
3-When active motion is limited secondary to sever pain and / or
anxiety.
The CPM parameter should be set so that the ROM goals are attained
and pain is minimized to achieve this, the following parameters should
be considered;
55. 1-The CPM should begin at 2 hours per day, and progress to 8
hours.
2-The patient should fitted in glove or stock net that the CPM device
can be attached.
3- The arc of motion should be within pain free range, after that small
adjustment is mad to increase arc of motion.
4-The CPM should be employed in conjunction with, self –care
activities, active exercises, and splinting.
However the use of CPM for burned patients is limited due to
1-Need of close monitoring (i.e. patients who resist motion of device)
2-Joint insatiability as in extensor tendon rapture.
3-Cost of the machine.
57. 7.Game therapy and fine motor skills
start with picking up small, firm, light weight objects and progress to handling large,
flexible, soft, and heavy objects.
Everyday activities such as writing, tying one’s shoelaces, and eating help exercise
the hand.
A simple task a physiotherapist can ask a patient to perform is to touch their thumb to
each finger.
Patients should also be encouraged to color and draw as this helps develop motor
control and accuracy.
To strengthen their grip and dexterity, patients can be asked to practice picking things
up.
More advanced version of this task is to have the patient pick up smaller objects like
toothpicks or soft, flexible objects like cotton balls. One could also have patients
button and unbutton a shirt.
58. Fascial burn
• The management of facial burns begins at admission.
• There are a number of important considerations during
the early post-injury period that can influence face burn
healing and reduce the risk of complications of facial
burns
59. Facial burns rarely occur as an isolated burn
Assess the extent of burn TBSA
Burned area should be gently washed with saline
All hair must be shaved with electric dipper
Blisters must be evacuated preserving its epithelium as a
biological dressing
The initial management prevents further complications
Gently debride the wounds
60. The head is elevated 30 degree to ease breathing &
minimize edema
Nostrils should be cleaned & apply nasogastric tube early
as the later edema will obstruct the procedure
Dressing every 6-8 hr will ease the debridement & prevent
dehydration
Apply topical agents for moisturing
Local antibiotics
Physiologic lubricating solutions to protect the cornea
Suitable splints to prevent deformities
61. Airway Control
• Many patients with facial burns sustain inhalation
injuries and are often intubated before or on admission
to the burn center
Eye and Eyelid Management
• Current eyelid management protocols include aggressive
lubrication in the days following
62. Physical Therapy Modalities
Facial exercises, orthotic and pressure devices can be
used to minimize facial complications.
Neck stretching exercise and facial massage:
Orthotic Devices and pressure treatment can be elastic
and rigid materials it may assist in the prevention and
reduction of contractures in hypertrophic scarring of the
facial skin.
Pressure therapy:
63. pressure garments or masks fitted early after injury.
The patient should begin scar massage as soon as wounds
heal.
Instruct patients to wear moisturizing sunscreen and avoid
direct sun exposure for the first 12 months following burn
scar healing and skin grafting. These precautions avoid
potential hyperpigmentation complications
68. Orthotic Devices :Horizontal, vertical and circumferential mouth-
opening devices are utilized to correct oral microstomia.
69. TENS application : it is used for pain relieve ( at any stage
of treatment .Acute-chronic –pre-operative and post-
operative stage )
Application ;Two or four electrodes applied on the course
of facial nerve .
LASER used for pain relieve, wound healing and scar
treatment (avoid eye during application)
Functional electrical stimulation :
It is used after healing of full thickness graft or flap ( i.e.
complete vascularization of graft) .
70. Deep friction massage:
It is used for loosening of scar, increase circulation and
increase pliability of skin.
PNF exercise:
It is used for facial muscles to improve facial expression,
strength of facial muscles and facilitation of facial movement.
