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REHABILILITATION OF HAND BURN

Introduction

A burn is an injury to body tissues from exposure to heat (i.e., flames, hot liquids or
gases, steam), electricity, chemicals, or radiation. Burns impair the ability of the skin to
prevent heat and water loss, and they eliminate the barrier the skin provides against
infection. The amount of skin surface injured, depth of the burn injury, and location of
the injury determine the seriousness of a burn injury.

A burn to the hand involves only a small percentage of the total body surface area
(TBSA); a burn of one side of the hand and fingers is estimated as 1% of TBSA, and a
burn of the entire hand is estimated as 2.5% of TBSA (Gómez). Nevertheless, any third-
degree or fourth-degree burn of the hand is considered severe. With burns of the wrist,
there is potential for impaired circulation, and in the hand, risk of disability arises from
decreased function due to permanent shortening and stiffening of muscles or tendons
(contractures).

Burns are described as first-, second-, third-, or fourth-degree based on the depth of tissue
damage; burn injuries often result in a combination of burn depths. A first-degree burn
affects only the topmost layer of the skin (epidermis) and causes redness without any
blistering. Sunburn is an example of a common first-degree burn.

A second-degree burn, known as a partial-thickness burn, involves deeper layers of the


skin and results in painful blisters. Superficial second-degree burns often result from
scalds. These burns may be very painful, but they generally heal in 2 to 3 weeks without
scarring. Deeper second-degree burns often result from contact with flames, hot oil, or
grease.

Third-degree burns are known as full-thickness burns. They affect the all layers of the
skin and also the layer of tissue below the skin (subcutaneous tissue). Third-degree burns
often are very pale and cause little pain at first, since all nerve endings have been
destroyed. These burns may result from flames, scalds, chemical exposure, or electrical
injuries. Individuals will develop significant scars and contractures of those joints
involved in the injury.

Fourth-degree burns are extremely severe; these burns are third-degree burns that extend
deeper into muscle and bone tissue. They sometimes cause the loss of hands or fingers.

Thermal burns are the most common burn of the wrist and hand. Thermal burns are due
to exposure to hot materials such as liquids (scalds), flames, (e.g., house fires) or steam
(e.g. car radiators). Chemical burns occur as a result of exposure to acid or alkali
chemicals or the deployment of automobile airbags.

Electrical burns are least common and occur when the body is exposed to an electric
current. Injuries are sustained at points where the current enters, passes through, and exits
the body. The most common sites of an electrical entrance wound are the hands and head.
Fingers and hands may be destroyed by electrical injury. Electric current may arc from
one object to another, such as from a wire to a hand tool, without entering the body. Such
arcs produce flash burns, or thermal burns from brief high intensity heat.

Diagnosis

History: Except in a third-degree burn that destroys nerve endings, the individual usually
reports significant pain. Large blisters may form at the burn area. The individual may
report other injuries sustained at the time of the burn.

Physical exam: In a first-degree burn, redness without blistering can be seen. In a


second-degree burn, there may be large blisters on the hands, wrist, or fingers. In a third-
degree burn, the skin may appear very pale. In a fourth-degree burn, injury extends into
muscle or bone. A combination of burn depths may be noted. In an electrical injury, signs
of injury may be seen between the entrance and exit wounds.

Tests: Testing is generally not needed for diagnosis of burns to the hand or wrist.
Treatment

Because the majority of individuals with burns presenting to emergency departments are
those with hand and wrist burns covering less than 1% of the body, fluid replacement
usually is not required due to the low risk for hypovolemic shock (Gómez). Pain
medication (analgesics) or sedation anesthesia may be provided before treatment of the
burn. The individual should receive immunization against tetanus. All jewelry must be
removed from the fingers and wrists to prevent constriction that may occur as swelling
(edema) increases following a burn.

Emergency treatment for first- and second-degree burns includes immersing the affected
area in cool running water for 10 minutes or more until the burning feelings subside. If
the victim is burnt through clothing, the clothing should be left on and immersed in
water. Care must be taken when treating a chemical burn. In most circumstances, water
lavage is appropriate. However, specific substances may require caution and lavage with
substances other than water. Alkaline burns are more difficult to treat as the injury often
progresses. Water lavage following exposure to lithium, potassium, phosphorus, and
sodium may cause ignition. Exposure to hydrofluoric acid may cause progressive damage
and application of 2.5% calcium gluconate gel or injection of calcium gluconate or
magnesium sulfate into the affected area may be beneficial. Individuals in contact with a
live electrical source following an electrical burn should not be pulled away; the current
should first be switched off, if possible, or the individual pushed away from the source
with a wooden stick or other item that does not conduct electricity. CPR and emergency
treatment are needed if the victim has stopped breathing.

Individuals with more than minor burns to the wrist and hand generally are admitted to
specialized burn centers. Treatment of second-degree burns may include cleansing,
removal of large blisters and dead skin (débridement), and application of an antimicrobial
burn ointment. If the burn is expected to take longer than 3 weeks to heal, burned tissue
(eschar) may be surgically removed (excised); skin taken from another area of the body is
then placed (grafted) on the burn to speed healing and minimize infection.

Third-degree burns require extensive treatment. The burn area is cleansed and débrided.
Repeated débridement may be necessary to fully determine the depth of the burn injury.
Excision and grafting usually are done to minimize the frequency of débridement and to
prevent infection. Non-adherent, semi-permeable membranes in the shape of a glove may
be used for wound dressings. In some cases specialized dressings can act as a scaffolding
layer to allow re-epithelialization of the burn wound; as the burn heals, the dressing
separates from the wound. With fourth-degree burns, especially those on the back side of
the hand and wrist (dorsal surface), exposed bones may need to be stabilized with pins
and wires to prevent contractures until the skin graft has healed. The majority of serious
burns to the hands and wrist are also treated with splinting to prevent contractures.
Elevation of the injured hand(s) is essential to reduce edema.
If eschar impairs circulation to the hand or fingers or encircles the extremity
(circumferential burn), an incision is made through the burn to relieve the tightness and
allow adequate circulation (escharotomy). Amputation of the fingers or hand may be
necessary for severe burn injuries where circulation is absent or when bone and tissue are
destroyed.

Long-term treatment includes prevention of infection, excision and grafting, nutritional


support, care of associated trauma and other medical conditions, and plastic surgery or
orthopedic repair to improve functioning of the fingers and hands. Long-term
rehabilitation may be needed.

Prognosis
More than 10,000 individuals die from burn injuries each year (Demling) with an
overall survival rate of 94.4% (“Burn Injuries”). Structural fires are
responsible for up to 45% of deaths from burns; chemical and electrical burns
account for 5% of deaths (Demling). The outcome varies depending on the
severity of the burn. Amputation of fingers or the hand is a possibility. Full
function of the hands and fingers may be permanently lost. If the thumb is
involved, up to 50% of hand function may be lost (Nugent).

First-degree burns begin to heal in a few days and are typically healed within
1 week with no scarring (“Burns”). Superficial second-degree burns without
infection heal spontaneously in about 2 to 3 weeks without scarring or
impairment of function (“Burns”). With deeper burns, healing may take
several months if no infection occurs; however, scar formation is significant in
deep burns. Significant third- or fourth-degree burns will not heal properly
without skin grafting. Skin grafting improves the outcome by providing a
permanent transplantation of skin from other parts of the body to replace skin
lost in the burn injury. The appearance of grafted skin may vary. Sometimes
blends into nearby healthy skin very well, but other times there may be a
distinct mark between normal skin and the grafted skin. Rehabilitation should
be started as soon as the graft heals, ideally within 2 to 3 weeks after injury, to
restore functional movement and minimize the risk for joint contractures
(“Burns”).
Rehabilitation

Hand and wrist rehabilitation after a burn depends on


the severity of the burn. Superficial and some
partial-thickness burns may not require any formal
therapy. Deep burns may require a combined
rehabilitative program of splinting, stretching, and
exercise. Splinting the hand and wrist in a specific
position prevents further loss of motion from
damage to tendons, joints, or skin grafts. Stretching
and exercise for any depth of burn focuses on
keeping the healing tissue supple to allow return to
function. Without exercise, the individual will
develop excessive scar tissue and muscular atrophy,
which leads to permanent loss of function and
possible disfigurement.

Early in rehabilitation, the individual typically


experiences great pain when performing any
exercise. Therefore, the therapist must clearly
outline the exercise plan and make the individual
fully aware of the consequences of not performing
the prescribed exercises. In rare cases when pain is
too great or the individual exhibits an excessive fear
response toward exercise, the individual may
undergo therapy under anesthesia before surgical
procedures such as skin grafting.
Initially, therapists instruct alert and responsive
individuals to perform active range of motion
exercises. The therapist also teaches the individual
breathing techniques to reduce anxiety from
anticipation of pain, which may cause muscle
guarding and stiffness. If the individual remains
unconscious or unresponsive due to a severe injury
or burn, the therapist may manipulate the fingers or
wrist (passive range of motion). The number of
repetitions and duration of the exercise session is
determined by the individual's level of pain, as well
as the depth of the burn. Therapists also must
evaluate the potential for tendon rupture due to
tissue weakness following a burn. If skin grafting
has occurred, caution must be used to avoid
excessive stress from movement on the newly
grafted tissue, which may cause graft separation.

Once complete range of motion of the wrist or


fingers is restored, the individual may perform
progressive resistive exercises while wearing a
pressure glove that is used to reduce disfiguring scar
tissue formation. The pressure glove should be worn
22 to 23 hours each day and removed only to bathe
or massage the scar tissue. Other modalities, such as
neuromuscular stimulation, may be used to help
strengthen muscles and restore hand and wrist
function in conjunction with active exercise.

By the end of the third month or when all wounds


are closed, the individual may participate in a work-
conditioning program to identify any potential
problems on re-entering the work force. An
occupational therapist or certified hand therapist
will evaluate the different hand motions needed for
work activities and simulate them in rehabilitation
therapy to restore the necessary strength and
flexibility for return to work.

Complications
In the first 72 hours after the burn, fluid may
accumulate in the compartments of the hand, with
blood flow decrease and pressure increase
(compartment syndrome); uncontrolled edema is a
dangerous condition that may require an emergency
fasciotomy in which incisions are made in the
muscles of the hand to relieve pressure. Other
complications are impaired blood circulation,
decreased movement, infection, and loss of fingers
due to constriction by eschar.

Hand contractures are a major complication of a


wrist and hand burn, with 23% of hospitalized
individuals experiencing at least 1 contracture; on
average, individuals with at least 1 contracture will
sustain as many as 10 contractures throughout their
recovery (Schneider). The wrist joint is the most
frequently involved, representing 22% of hand
contractures (Schneider).

Return to Work (Restrictions / Accommodations)

Work restrictions and accommodations vary depending


on the severity of the burn and job responsibilities.
Restrictions are not usually required for minor
burns of the hands and wrists. For severe burns,
several months of time off for recovery and surgical
procedures may be needed. Compressive dressings
may need to be worn for several months to minimize
scar formation. The fingers and hands may be weak
or stiff, and full function of the hands and fingers
may be permanently lost. If fingers or hands were
amputated or if burns occurred to other parts of the
body, job reassignment may be necessary. The
individual may require frequent follow-up
appointments. If pain medication is needed,
company policy on medication use should be
reviewed to determine if medication usage is
compatible with job safety and function.

Before the individual returns to work, skin


irritation problems such as garment friction during
repeated hand movements should be identified.
Adaptive equipment may be needed such as thicker
and built-up railing handles or arms of chairs to
assist in gripping.