Update on the Practice of Splinting During Acute Burn Admission From the ACT Study.

Burn scar contracture (BSC) is a common pathological outcome following burn injuries, leading to limitations in range of motion (ROM) of affected joints and impairment in function. Despite a paucity of research addressing its efficacy, static splinting of affected joints is a common preventative practice. A survey of therapists performed 25 years ago showed a widely divergent practice of splinting during the acute burn injury. We undertook this study to determine the current practice of splinting during the index admission for burn injuries. This is a review of a subset of patients enrolled in the Burn Patient Acuity Demographics, Scar Contractures and Rehabilitation Treatment Related to Patient Outcome Study (ACT) database. ACT was an observational multicenter study conducted from 2010 to 2013. The most commonly splinted joints (elbow, wrist, knee, and ankle) and their seven motions were included. Variables included patients' demographics, burn variables, rehabilitation treatment, and hospital course details. Univariate and multivariate analysis of factors related to splinting was performed. P < .05 was significant. Thirty percent of the study population (75 patients) underwent splinting during their hospitalization. Splinting was associated with larger burns and increased injury severity on the patient level and increased involvement with burns requiring grafting in the associated cutaneous functional unit (CFU) on the joint level. The requirement for skin grafting in both analyses remained independently related to splinting, with requirement for grafting in the associated CFU increasing the odds of splinting six times (OR = 6.0, 95% CI = 3.8-9.3, P < .001). On average, splinting was initiated about a third into the hospital length of stay (LOS, 35 ± 21% of LOS) and splints were worn for 50% (50 ± 26%) of the LOS. Joints were splinted for an average 15.1 ± 4.8 hours a day. The wrist was most frequently splinted joint being splinted with one third of wrists splinted (30.7%) while the knee was the least frequently splinted joint with 8.2% splinted. However, when splinted, the knee was splinted the most hours per day (17.6 ± 4.8 hours) and the ankle the least (14.4 ± 4.6 hours). Almost one third had splinting continued to discharge (20, 27%). The current practice of splinting, especially the initiation, hours of wear and duration of splinting following acute burn injury remains variable. Splinting is independently related to grafting, grafting in the joint CFU, larger CFU involvement and is more likely to occur around the time of surgery. A future study looking at splinting application and its outcomes is warranted.

Goniometric Measurement of Burn Scar Contracture: A Paradigm Shift Challenging the Standard.

Standard goniometry is the most commonly used method of assessing the range of motion (ROM) in patients with burn scar contracture. However, standard goniometry was founded on arthrokinematic principles and doesn't consider the cutaneous biomechanical influence between adjacent joint positions and skin pliability to accommodate motion. Therefore, the use of standard goniometry to measure burn scar contracture is called into question. This prospective, multicenter, comparative study investigated the difference between standard goniometry, based on arthrokinematics and a revised goniometry protocol, based on principles of cutaneokinematics and functional positions to measure ROM outcome in burn survivors. Data were collected for 174 joints from 66 subjects at seven burn centers totaling 1044 measurements for comparison. ROM findings using the revised protocol demonstrated significantly more limitation in motion 38.8 ± 15.2% than the standard protocol 32.1 ± 13.4% (p < .0001). Individual analyses of the motions likewise showed significantly more limitation with revised goniometry compared with standard goniometry for 9/11 joint motions. Pearson's correlation showed a significant positive correlation between the percentage of cutaneous functional units scarred and ROM outcome for the revised protocol (R2 = .05, p = .0008) and the Δ between the revised and standard protocols (R2 = .04, p = .0025) but no correlation was found with the standard goniometric protocol (R2 = .015, p = .065). The results of this study support the hypothesis that standard goniometry underestimates the ROM impairment for individuals whose motion is limited by burn scars. Having measurement methods that consider the unique characteristics of skin impairment and the impact on functional positions is an important priority for both clinical reporting and future research in burn rehabilitation.

Burn Patient Acuity Demographics, Scar Contractures, and Rehabilitation Treatment Time Related to Patient Outcomes: The ACT Study.

In 2008, the U.S. Department of Defense funded a rehabilitation study through the American Burn Association titled "Burn patient acuity demographics, scar contractures, and rehabilitation treatment time related to patient outcomes," commonly known at the ACT study. The ACT was a multi-institutional, prospective, observational, and quasirandomized investigation of the acute hospital course of 307 patients. The ACT specifically emphasized the capture of factors that may impact the physical outcome of patients with burn injury including burn severity, daily rehabilitation interventions such as mobility and splinting, and detailed skin grafting episodes. In particular, the effect that the amount of daily rehabilitation time patients received as it related to range of motion measured at the time of acute hospital discharge of areas affected by the burn injury was analyzed. The information contained herein is intended to give the interested reader an overview of the extent and breadth of the ACT dataset in terms of parameters available for further investigation. This information is also intended to be used as a basic reference for conduct of the ACT study in future reports.

Burn Hand or Finger Goniometric Measurements: Sum of the Isolated Parts and the Composite Whole.

Accurate assessment of hand function following a burn is important for patient impairment determination. Goniometric measurement of hand or finger range of motion (ROM) is typically done measuring individual finger joints with the adjacent joint in extension (isolated) or measuring the joints in a fist position (composite). The purpose of this study was to compare if the total flexion motion of the summed angles of the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints in burned hands were equal when performed in an isolated vs a composite manner. Passive flexion ROM angles were collected prospectively and measured at the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal with the adjacent joints extended to measure isolated angles and with the adjacent joints fully flexed for composite angles. Thumb joints were excluded. ROM for isolated and composite positions of eight fingers was compared individually and as an aggregate. Finger measurements from 145 adult patients were compared. The study population was predominately male (69%) with a mean age of 41 ± 16.6 years. Mean total burn size was 14.2 ± 13.2%. A total of 739 fingers contributed 2217 joint ROM comparisons. Aggregate analysis of isolated ROM was 235.5° ± 52.1° compared with composite ROM of 226.8° ± 53.2° (P < .0001). Individual fingers showed significant differences between the two measurement methods as well (P ≤ .0040). The methods used to measure hand or finger ROM profoundly influence how hand impairment is reported. Measurement of isolated joint angles results in greater ROM values compared with composite angles, which are often more relevant for functional hand positions. Therefore, composite angles are recommended.

Profile of Patients Without Burn Scar Contracture Development.

Burn scar contractures (BSCs) are a frequently recognized problem for survivors of burn injury. In the burn literature, many reports focus on the frequency and factors associated with the BSC development. To the contrary, few burn rehabilitation publications report on patients who are able to successfully avoid developing BSC. From a prospective, multicenter study, data were extracted and reviewed on a group of 56 adult burn survivors who were discharged from their acute hospitalization without any measured BSCs. Forty-three variables with a recognized or presumed association with the development of BSCs were analyzed and are reported. Highlighted features of the noncontracted group included being an adult male with an educated background and few associated physical, medical, or social problems. The group had relatively small burn sizes that nonetheless required hospitalization. Despite the overall TBSA, the majority of the burn areas required skin grafting, although this area also represented a small area. The patient group had a longer than expected hospital stay. Rehabilitation was provided to patients on 80% of their hospital days. In addition, patients received sufficient rehabilitation treatment based on the number of cutaneous functional units involved in the burn injury. Patients were judged to have a high pain tolerance and compliant with rehabilitation. The results of this study document the clinical circumstances that patients with burn injury can be discharged from their acute hospitalization with the development of BSC. This study challenges the rehabilitation personnel to expand the upper limit of burn severity that can result in similar positive outcomes.

Hierarchical decomposition of burn body diagram based on cutaneous functional units and its utility.

A burn body diagram (BBD) is a common feature used in the delivery of burn care for estimating the TBSA burn as well as calculating fluid resuscitation and nutritional requirements, wound healing, and rehabilitation intervention. However, little change has occurred for over seven decades in the configuration of the BBD. The purpose of this project was to develop a computerized model using hierarchical decomposition (HD) to more precisely determine the percentage burn within a BBD based on cutaneous functional units (CFUs). HD is a process by which a system is degraded into smaller parts that are more precise in their use. CFUs were previously identified fields of the skin involved in the range of motion. A standard Lund/Browder (LB) BBD template was used as the starting point to apply the CFU segments. LB body divisions were parceled down into smaller body area divisions through a HD process based on the CFU concept. A numerical pattern schema was used to label the various segments in a cephalo/caudal, anterior/posterior, medial/lateral manner. Hand/fingers were divided based on anatomical landmarks and known cutaneokinematic function. The face was considered using aesthetic units. Computer code was written to apply the numeric hierarchical schema to CFUs and applied within the context of the surface area graphic evaluation BBD program. Each segmented CFU was coded to express 100% of itself. The CFU/HD method refined the standard LB diagram from 13 body segments and 33 subdivisions into 182 isolated CFUs. Associated CFUs were reconstituted into 219 various surface area combinations totaling 401 possible surface segments. The CFU/HD schema of the body surface mapping is applicable to measuring and calculating percent wound healing in a more precise manner. It eliminates subjective assessment of the percentage wound healing and the need for additional devices such as planimetry. The development of CFU/HD body mapping schema has rendered a technologically advanced system to depict body burns. The process has led to a more precise estimation of the segmented body areas while preserving the overall TBSA information. Clinical application to date has demonstrated its worthwhile utility.

Refining the idiom "functional range of motion" related to burn recovery.

The term "functional" in burn rehabilitation has gained widespread use to describe a patient's recovery after burn injury. But what truly is "functional" when applied to a patient recovering from burn injury? A literature search was performed for information defining "functional" range of motion (ROM). Maximum upper and lower ROM values to perform a variety of daily activities were abstracted and compared with published outcomes of patient groups recovered from burn injury. Seventy references were reviewed leading to categorizing 11 activities and 26 joint motions. Seven burn outcome articles were found that classified patient scar contracture severity based on ROM. In comparing the results, many burn survivors with severe burn scar contractures could be considered "functional." Refinement of the term "functional" is needed related to burn outcomes. Functional ROM of a particular joint to perform one specific task may be insufficient to perform a variety of other tasks when all planes of motion are considered. Use of the term "functional" to describe a patient's outcome should be used in a guarded manner.

Positioning, splinting, and contracture management.

Whether a patient with burn injury is an adult or child, contracture management should be the primary focus of burn rehabilitation throughout the continuum of care. Positioning and splinting are crucial components of a comprehensive burn rehabilitation program that emphasizes contracture prevention. The emphasis of these devices throughout the phases of rehabilitation fluctuates to meet the changing needs of patients with burn injury. Early, effective, and consistent use of positioning devices and splints is recommended for successful management of burn scar contracture.

Burn rehabilitation and research: proceedings of a consensus summit.

Burn rehabilitation is an essential component of successful patient care. In May 2008, a group of burn rehabilitation clinicians met to discuss the status and future needs of burn rehabilitation. Fifteen topic areas pertinent to clinical burn rehabilitation were addressed. Consensus positions and suggested future research directions regarding the physical aspects of burn rehabilitation are shared.

Military return to duty and civilian return to work factors following burns with focus on the hand and literature review.

Functional recovery and outcome from severe burns is oftentimes judged by the time required for a person to return to work (RTW) in civilian life. The equivalent in military terms is return to active duty. Many factors have been described in the literature as associated with this outcome. Hand function, in particular, is thought to have a great influence on the resumption of preburn activities. The purpose of this investigation was to compare factors associated with civilian RTW with combat injured military personnel. A review of the literature was performed to assimilate the many factors reported as involved with RTW or duty. Additionally, a focus on the influence of hand burns is included. Thirty-four different parameters influencing RTW have been reported inconsistently in the literature. In a military population of combat burns, TBSA burn, length of hospitalization and intensive care and inhalation injury were found as the most significant factors in determining return to duty status. In previous RTW investigations of civilian populations, there exists a scatter of factors reported to influence patient disposition with a mixture of conflicting results. In neither military nor civilian populations was the presence of a hand burn found as a dominant factor. Variety in patient information collected and statistical approaches used to analyze this information were found to influence the results and deter comparisons between patient populations. There is a need for a consensus data set and corresponding statistical approach used to evaluate RTW and duty outcomes after burn injury.

Combat casualty hand burns: evaluating impairment and disability during recovery.

This study evaluated the use of the American Medical Association (AMA) impairment guides and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire in U.S. military casualties recovering from burn injury to the hand. Study sample included patients with burns to at least one hand and complete evaluations of impairment and disability upon discharge from the hospital and at a follow-up visit less than four months later. AMA and DASH scores were calculated for each visit and standardized response means (SRMs) were calculated to indicate responsiveness. Correlation between impairment and disability was assessed at discharge and follow-up and scores were examined for ability to discriminate between casualties returned to duty (RTD) and casualties not returned to duty (N-RTD). Both outcome instruments revealed a statistically significant change in scores between visits (p<0.001) with corresponding SRM indexes greater than 0.8 (large effect). There was a moderate correlation (r=0.50) between impairment and disability at discharge and a moderately high correlation (r=0.74) at follow-up. Both AMA and DASH scores clearly discriminated between casualties RTD (AMA 10+/-10 and DASH 12+/-12) and casualties N-RTD (AMA 39+/-19 and DASH 41+/-17) with improved accuracy at follow-up visit. The AMA and DASH can provide a comprehensive assessment of impairment and disability and may be used to detect changes in patient health status over time while clearly discriminating between RTD and N-RTD in combat casualties recovering from burn injury to the hand(s).

A review of compression glove modifications to enhance functional grip: a case series.

A common complaint among patients with burns is their inability to grasp items while wearing compression gloves. Recent technological innovations permit the addition of grip-enhancing material to garment fabric. The purpose of this case series was to describe the course of development of compression gloves with enhanced grip modifications. Five different types of grip modifications were made during a period of 18 months. Five subjects who were prescribed compression gloves tested each type of glove. The gloves were fabricated with grip-enhancing material on the palmar surface in five ways: 1) rectangular rubber tabs; 2) honeycomb pattern silicone; 3) wave-like pattern silicone; 4) line pattern silicone beads; 5) line pattern silicone beads embedded into the fabric. Each glove was evaluated on a three-point Likert scale (0 = poor, 1 = moderate, 2 = good) for grip-enhancing qualities and durability. All five subjects reported similar experiences with each glove type: 1) the rectangular rubber tabs demonstrated poor grip and moderate durability; 2) the honeycomb pattern provided good grip but poor durability; 3) the wave pattern had good grip and moderate durability; 4) the silicone beads adhered to the fabric had moderate grip but poor durability; 5) the silicone beads embedded into the fabric had moderate grip and good durability. The wave pattern provided the best gripping capability and silicone embedded into the fabric demonstrated the best durability. A wave-like pattern silicone material embedded into the fabric seems to provide the best combination of grip and durability to enhance activities of daily living performance.

Splinting strategies and controversies.

Splinting is a common burn care intervention strategy based on logical anatomic and biomechanical principles. The persistence of scar contraction requires countermeasures, frequently splints, and most clinicians would concur that splints are valuable in opposing these contraction forces. Clinical decisions about splinting are often made on respected opinion, leading mainly to design and application options. Variables that affect splinting strategy include the risk-to-benefit ratio of the splint, the timing of the application, the choice of splint design, and duration of the splinting intervention. The most common of these variables reported in the literature is simply unique designs for splints. Although there are different splint designs for similar problems, no data exist to favor one design over another. Controversy about splinting in burn care is not based on the rationale for and success of splinting but exists because of the paucity of validation of its use.

Partial-thickness burns: identification and management.

PURPOSE: To provide an overview of the appropriate evaluation and management of partial-thickness burns. TARGET AUDIENCE: This continuing-education activity is intended for physicians and nurses with an interest in learning about burn wound care. LEARNING OBJECTIVES: After reading the article and taking the test, the participant will be able to: 1. Describe the classification of burn wounds. 2. Identify characteristics of burn wounds and the clinical techniques for diagnosing burn wound depth. 3. Identify the treatment options for partial-thickness burns.