Burns, Flaps, & Grafts

BG A medical product that is now available over the counter and is used in many therapy clinics to improve characteristics of scar tissue formation in web spaces of the thumb, digits and concave surfaces is what?

1) Otoform © elastomer 2) Silicone inserts Elastomer Extra Catalyst: like silicone, it is used in conjunction with splints, burn garments or gloves to aid in scar remodeling and healing. Ideal for curved areas such as hands, faces, fingers and web spaces. Sets up at room temperature in 5 to 6 minutes. Each size comes with one catalyst, with additional catalysts sold separately. Latex free.

BG Dressings used for wounds associated with burns include?

1) Sliver nitrate 2) Silvadene

BG List at least 4 different types of compression used clinically to decrease edema, flatten scars, and possibly decrease collagen formation.

1) Tubigrip © 2) Elastic wraps - Example: Coban © 3) Customized pressure garments 4) Anti-edema gloves - Example: Isotoner gloves

Burns FLAPS (full thickness skin graft) how are flaps different from grafts?

A flap is a portion of skin and or subcutaneous tissue and muscle that contains its own vascular supply. It is tissue that is attached temporarily or permanently to its donor site by a pedicle through which vascularization is maintained. Survival of this tissue does not depend on the status of the recipient bed. The blood for the flap is supplied through the segmental vessels to their perforating vessels. If the pedicle is connected through microsurgical anastomosis to recipient vessels at the receiving site the flap is considered a free flap. A pedicle is the flap that provides the blood supply. The flap receives its blood supply from a source other than its own.

Burns Surgical Intervention and Reconstruction Skin Grafts What is the most common cause of skin graft failure?

A hematoma is the most common cause of skin graft failure

Burns FLAPS (full thickness skin graft) what is a pedicle?

A pedicle is the flap that provides the blood supply. The flap receives its blood supply from a source other than its own.

BG What is a web-band contracture?

A web-band contracture restricts only abduction and often is a result of a palmar burn.

Burns Split Thickness Skin Graft (STSG) Advantages?

Advantages include large supply of donor areas, ease of harvesting, reusable donor sites, decreased primary (early) contracture, and the ability to cover large surface areas.

Burns FLAPS (full thickness skin graft) What are the advantages of flaps?

Advantages of flaps include better cosmesis, increased durability, improved sensibility and decreased contractures.

Custom Pressure Garments Creams: Aloe vera has been shown, when applied to wounds, to exhibit a shorter wound healing time compared to:

Aloe vera has been shown, when applied to wounds, to exhibit a shorter wound healing time compared to dry gauze dressings. The concept of inducing moist wound environments as compared to dry is considered a key principle in wound healing.

BG What is the difference between a random pattern flap and and axial pattern flap?

An axial flap receives its blood supply from a single "pedicle" vs layers of vessels seen in a random pattern of blood supply

Burns Orthotics Common positions of deformity include: (feet)

Ankles (foot drop) - orthotics - should be considered within the first 24 hours if limited motion occurs - orthotics are indicated if a patient can't voluntarily maintain stretch of skin and soft tissue structures - disinfect orthotics after each dressing change - orthotics in the position of anti-deformity - safe position

Burns Pain management immersive virtual reality what is DITTO?

Another study investigating the effect of a distraction device called DITTO engages children in a preparatory interactive story tailored to ages 3-12. The story aims to desensitize the child during wound care procedures, reducing fear and anxiety and instilling an element of control. Results from the trial confirmed the effectiveness of DITTO in reducing pain and treatment length.

Burns Flap Classifications - Vascular Axial

Axial - single pedicle flaps that receive their blood supply from a single constant vessel. These flaps are based on cutaneous or muscular artery. Ex: groin, scapular and temporoparietal

Burns EXERCISE/MOTION Early pressure: When does it start? What re the effects of early pressure?

Begins at 72 hours, and the constant pressure on the healing wound will cause close approximation of collagen bundles by stimulating collagen cross linking and reorganizing collagen into parallel fibers. This will help minimize scar hypertrophy and improve the outward appearance of the scar. Constant pressure will also help to diminish vascular and lymphatic pooling and helps to reduce hypersensitivity of the skin. Compression must be worn 23 hours a day for two years to be effective. It is not uncommon for the patient to have several interim pressure bandages while they wait for a custom/commercial glove or until he/she can tolerate a commercial glove.

Burns Surgical Intervention and Reconstruction Skin Grafts The following common characteristics are listed for both split and full thickness skin grafts:

Both are tissues detached from their native blood supply Both depend 100% on the recipient bed for their revascularization. - Therefore, recipient beds with good blood supply have a better survival rate

BG The definition of eschar is?

Burned, black tissue

Complications of Hand Burns The following complications can be associated with hand burns: Claw hand deformity:

Can occur from many factors - damage to the extensor mechanism, scar contracture to the dorsum of the MPJ, hyperextension of the MPJ as a result of extensor mechanism relaxation, or volar burns pulling the IPJ's into flexion.

Burns Initial Evaluation Part II

Cause of burn Hand dominance Sensation Edema Vascularity Baseline AROM Muscle performance Fisting patterns Prehension and grasp patterns Dexterity/coordination/opposition Intrinsic/extrinsic muscle tightness Skin integrity Functional limitations ADL status Patient goals

Complications of Hand Burns The following complications can be associated with hand burns: Web space syndactyly: what is it and how is it treated?

Caused from a burn in the web space and can lead to progressive contracture and narrowing of web space between any of the digits. Treat with: - Scar massage - Stretching - Static or dynamic orthotics - Pressure

Burns FLAPS (full thickness skin graft) causes of skin flap failure include?

Causes of skin flap failure include: infection, hypotension, tension on graft, hematoma, and hypoxia linked to cigarette smoking and insufficient blood supply.

Burns Edema Management: what has been shows to contribute to edema formation?

Clinical gem: For many years, fluid shift was thought to be caused by an increase in capillary permeability. However, research has shown that increased capillary permeability is contributory to edema formation; burn-induced edema in the emergent phase is caused primarily by interstitial components generating a strong negative tissue pressure.

Burns Orthotics What position is used to counteract deforming forces?

Clinical gem: The tenodesis effect is the philosophy used when applying orthotics to the burn hand. To counteract the position of deforming forces and to protect the structures of the hand, an orthotic that positions the hand in wrist extension, MPJs in flexion, IPJs in extension, and thumb away from the palm is effective. Placing the wrist in extension induces MPJ flexion by action of the extrinsics or the tenodesis effect. When the PIPJs and DIPJs are positioned in full extension and the MPJ in flexion the extensor mechanism is placed on slack; hence decreasing the stress on the PIPJ allowing the collateral ligaments to be elongated.

Burns Monitoring Skin Flap Viability

Color Capillary refill Dermal bleeding Fluorescent dye - intravenous injection of dye

Burns Initial Evaluation Part I

Components of the evaluation will vary dependent on stage and extent of injury. Initial evaluation Scar maturation/mobility Age/occupation Family support system/social history Date and mechanism of Injury Medical history (co-morbidities, medications) Surgical intervention/procedures Stage of recovery Review of complicating factors (infection, bone, nerve, tendon injury) Assessment of treatment precautions Pain assessment Wound assessment TBSA (total burn surface area)

Burns Edema Management: compression, wound care, and elevation

Compression is not used in the very early phase due to risking the venous return - however edema is usually quite significant in this early phase. Wound care - dressing is used to protect the wound against infection, provides for early pressure and provide comfort. Dressings must not be restrictive, as you don't want the patient to be discouraged from moving. Elevation and AROM are mainstays of management in the early phase. Elevation will assist with venous return and prevents pooling of fluid from being in a dependent position.

Burns EXERCISE/MOTION Early pressure: types of early pressure

Compressive dressings Fine mesh gauze between web spaces of digits to prevent syndactyly Custom fit garments can be applied when there are no open areas larger than the size of a quarter (or dime size when over a joint)

Burns Post Healing Facts:

Contracting forces are prevalent during scar maturation Forces may last for 9 months to 2 years Scar bands form at web spaces and on palmer surfaces at the creases Dorsal burns over the MP's will contract and pull into hyperextension Dorsal burns over the central slip will lead to boutonniere deformities Skin is the most involved and restricted structure in burn contractures Sustained stretch is the most effective technique for lengthening bands of scar tissue and increasing ROM Stretching can be performed to the point of blanching - be sure to remove dressings or PG so you can visualize it.

Burns EXERCISE/MOTION Coordination:

Coordination: Fine motor control is often a limitation following burn injuries to the hands and digits. Various exercises to promote fine motor control and optimal dexterity are also encouraged and should be integrated into the treatment setting.

Burns Surgical Intervention and Reconstruction Skin Grafts Grafting means tissue transfer without preservation of blood supply What kind of tissue is unsuitable for grafting, which are suitable?

Cortical bone, tendons, nerves and cartilage are not suitable surfaces for grafting Most other tissues are suitable for grafting - muscle, fat, fascia, dura or periosteum

BG What is a therapy goal prior to a STSG procedure?

Critical to have obtained FULL ROM before grafting. Immobilization typically is 4 to 5 days after the procedure (STSG) and often an anti-deformity orthosis to include the wrist, MPJ, IPJ, and thumb is fabricated in the operating room (OR).

Burns Specific Flaps to Review: Cross finger

Cross finger - a flap using dorsal skin and subcutaneous tissue from the middle phalanx of an adjacent finger was first described in 1950. The standard cross-finger flap is best performed for cases of volar fingertip pulp amputation, particularly if bone is exposed. Division occurs at about day 8 - 9. Coverage for the donor site is required.

BG A burn scar contracture over what area________ results in extensive contractures of the DIPJ and nail deformities?

DIPJ Most of the time a release is required with a graft or a flap. Pain is often a significant symptom from the sensitive DIPJ being pulled into hyper-extension.

BG What is another term for a deep partial-thickness burn?

Deep second-degree burn or superficial 3rd degree Note: involves damage to the epidermis and the dermis. These burns (if insensitive to light touch) will be painful to deep pressure.

Burns Surgical Intervention and Reconstruction Skin Grafts Dermis

Dermis - Collagen in this layer is a fibrous protein deposited by fibroblasts that hold us together - The collagen as it is laid down gives a wound strength, responsible for elasticity - The major blood supply to the skin lies here - The subcutaneous tissue is not a true part of epidermis or dermis is deep to the dermis and a functional part of the skin

Burns Pain management Pain related to HYPERSENSITIVE SCARS are a common occurrence in the recovery of burns and can be treated with the following:

Desensitization with various textures Vibration Massage Scar/gel pads

Burns Split Thickness Skin Graft (STSG) Disadvantages

Disadvantages include cosmetic, hyper-pigmentation, decreased durability, and increased late contracture. After the grafts are harvested they can be meshed to expand the surface area.

Complications of Hand Burns The following complications can be associated with hand burns: Loss of the transverse metacarpal arch of the hand:

Due to being in a position of deformity.

Burns ROM how should Early AROM be performed after a burn?

Early AROM to control edema - AROM must be forceful enough to provide a pumping action and assist with venous blood and lymph return to central circulation

Burns Edema Management: Why is early edema control important?

Early control of edema is essential to promote normal range of motion and decrease stiffness. In the acute setting, elevation, positioning, orthotic fabrication and ROM exercises are the mainstays of treatment of burns (following any contraindication for tendon /nerve repair or grafting).

Burns Edema Management: how long does it take edema to develop after injury?

Edema develops anywhere from 8 to 12 hours; peaks at 36 hours and typically is completely gone by 7 to 10 days after the injury.

Phases of recover Therapists see burn injuries in all stages of recovery. The main stages of recovery are:

Emergent (first 72 hours) Acute Reconstruction (skin grafting) Rehabilitation

Burns FLAPS (full thickness skin graft) when are flaps used?

Flaps are a more complex part of the burn reconstruction process and are used instead as an alternative to skin grafts on the hand. Flaps are used when there is need to cover exposed bone, tendon or cartilage. Flaps are preferred when there is a high risk of skin contracture such as over joints and the tendons of the hand.

Burns FLAPS (full thickness skin graft) How are flaps classified?

Flaps are classified by method of transfer, destination, geometry, and tissue composition.

Burns ROM What should not be performed? Why?

Forceful and aggressive PROM is unnecessary to achieve motion and should not be performed. Aggressive PROM results in increased collagen and, subsequently, increased scarring. It is important to make sure dressings are removed with ROM so you can assess scar band blanching.

Burns Split Thickness Skin Graft (STSG) What is the primary cause of skin graft failure?

GEM: Primary causes of skin graft failure include hematoma and infection (Hazini, Whitney & Wilhelmani, 2012). Patients are advised to avoid the sun for six months post grafting to prevent permanent skin discoloration.

Burns ROM How should AAROM/PROM be performed?

Gentle AAROM and PROM may be performed in the early phase but caution should be used, as forceful PROM may disrupt healing tissue and add additional inflammation and swelling to the tissue--resulting in increased scarring and stiffness. PROM can be necessary if the pt has difficulty performing AROM (e.g. a small child).

Burns ROM What is the goal of early exercise?

Goal of early exercise is to stretch healing skin, maintain full ROM, preserve function and coordination, maintain strength, prevent tendon shortening, prevent scar adherence, and minimize contracture

Burns Split Thickness Skin Graft (STSG) Protocol/timeline

Graft take is usually noted by day 4 or 5. AROM begins at day 5-7 post grafting Gentle PROM begins at day 5-7 if graft has taken well. Use pressure garments by approximately day 10-14 depending on wound closure to minimize late contracture. - Carefully avoid shearing forces. Order the garment when wounds are almost closed.

Burns Pain management How does immersive virtual reality work?

Hoffman et al (2007) discovered through neuro-imaging that specific areas of the brain involved in the perception of pain showed significant reductions in pain-related brain activity when comparing treatment with virtual reality vs no virtual reality. In addition, patients have reported decreased pain with the use of virtual reality in the recovery process.

Burns Edema Management: why is it important to control edema early on?

If edema is not controlled this can be detrimental to overall hand function. Early control of edema helps to minimize scarring and decrease stiffness. Edema compromises circulation and limits joint mobility. Protein rich components of edema not quickly resolved organize around joint capsules, ligaments and form scar tissue.

Complications of Hand Burns The following complications can be associated with hand burns: Adduction contractures of the thumb: What is important to do ASAP?

If this occurs, pt will have limited prehension, overall mobility will be limited, and thumb growth may be restricted in children. It is difficult to correct once contracted; therefore, early aggressive treatment is recommended with c-bar orthotic.

Burns Surgical Intervention and Reconstruction Skin Grafts when should grafting be initiated?

Immediate debridement and grafting is optimal with no more than 2-3 days allowed to pass before grafting is initiated

Burns Split Thickness Skin Graft (STSG) Where is the graft harvested from?

Includes the epidermis and any portion of the dermis. Generally obtained from the thigh, buttock, or abdomen.

Burns FLAPS (full thickness skin graft)

Includes the epidermis and entire dermis. Used primarily for small defects on the palmer aspect of the hand. Obtained from the hypothenar eminence, medial aspect of the arm or groin. Hypothenar eminance provides good sensibility and "fingerprint" skin. Have better cosmesis, increased durability, improved sensibility and decreased late contracture. The donor site is closed after the graft is harvested. Donor sites are treated as any sutured wound. Flaps resemble skin more with regards to color, texture and hair growth.

Potential burn complications:

Infection (MRSA, sepsis, gangrene) Pruritis Oral contractures Heterotrophic ossification Loss of sensation Loss of sweat Contractures, scar contractures Hypertrophic scars Web space syndactyly Loss of thumb web space Loss of transverse metacarpal arch Claw hand deformity Amputation (partial or whole)

Burns, Flaps, & Grafts Burn Classifications: Full thickness (3rd Degree or sometimes 4th Degree):

Insensate, full thickness burns are considered the most severe as both the dermis and subcutaneous layers are damaged requiring surgical intervention including amputation, flap coverage and grafting. Initially the burned area is sometimes not painful since nerve endings are destroyed. Burned area may appear with thick eschar. Fourth degree burns. Fourth degree burns also damage the underlying bones, muscles, and tendons. There is no sensation in the area since the nerve endings are destroyed.

BG What is the name of the anti-deformity orthosis for forearm, hand and digits used during the emergent stage of burn healing?

Intrinsic plus orthotic

Burns Orthotics Potential burn orthoses consist of the following:

Intrinsic plus orthotic Watusi orthotic Foot drop orthotic Airplane orthotic C bar orthotic Digital extension orthotic Dynamic orthotics Static progressive orthotics Serial orthotics Static orthotics

Burns Edema Management: Clinical gem: Edema contributes to:

Ischemia FIbrosis Indurated tissue Deformities Decreased mobility Scar tissue Contractures Pain

Burns Edema Management: Clinical gem: Edema can cause the following:

Ischemia Fibrosis Compromised blood flow to the intrinsics can lead to intrinsic tightness Deforming position; limiting full AROM and full PROM Interferes with ADLs Scar tissue Contractures [Chronic edema can destroy or damage lymphatics.]

Burns Edema Management: In later stages, edema management consists of: Compression control techniques

Isotoner gloves® Tubigrip® Coban® Digital sleeves™ Ace® wraps Short stretch bandages Compression garments Some pressure garments (PG) have grip enhancements so patients can have increased functionality of the gloved hand

Burns EXERCISE/MOTION Early pressure: The following temporary pressure garments can be applied when wounds are healed until custom garments have arrived:

Isotoner® gloves Tubigrip® Coban® Ace wraps® Digital sleeves®

Custom Pressure Garments It is important to note that:

It is important to note that strong clinical evidence of the effectiveness of pressure garment therapy (PGT) is lacking. Despite the limited evidence supporting PGT, it is an extremely common therapy for the treatment of burns and associated edema.

Burns Specific Flaps to Review: Lateral V-Y advancement

Lateral V-Y advancement - a single v-shaped volar flap is cut from the remaining digital phalanx with the tip of the flap at the DIPJ crease. The flap is advanced and the donor defect is enclosed, as a Y. Tension free closure is mandatory. Typical advancement is about 5 mm on each side

Burns Flap Classification by Mobilization

Local - applies to fingertip coverage which is rotated about a point to reach a defect or to advance into the defect - Rotation - Transport - Interpolated - Advancement - Single pedicle - Bipedal

Burns Edema Management: In later stages, edema management consists of:

Lymphatic drainage - promotes lymphatic uptake Retrograde massage - promote venous return Exercise - promotes muscle pumping Functional "normal" use of the hand Kinesiotaping - provides route for edema movement Positioning - avoid dependent positioning to promote venous return (elbow in extension, forearm neutral, and the hand in the safe position) Elevation - prevents venous pooling Compression control

BG Acute burn management splints/orthoses should maintain what position?

MPJ @ 90 degrees flexion IPJ @ full extension This position decreases tension on joints, ligaments, and burned skin.

BG A common infection with burns is called?

MRSA

BG A manual clinical intervention aimed at reducing scar sensitivity is?

Massage

Burns Surgical Intervention and Reconstruction Skin Grafts When can massage be initiated? What are the benefits of massage?

Massage can be initiated when wounds are closed - this assists in lubrication, prevention of skin breakdown, increasing skin pliability, early desensitization; has been said to reduce patient complaints of itchiness.

Custom Pressure Garments Massage is a tool to aid in decreasing what?

Massage is a tool to aid in decreasing hypersensitivity of scar tissue, reducing pain and edema as well as patient complaints of itching.

Burns Split Thickness Skin Graft (STSG) Meshed vs Sheet Grafts

Meshed grafts are not cosmetically appealing; meshed grafting has the advantage of allowing for as much as four times increased surface area for burn coverage, and provides optimal drainage of blood and exudates which promote graft adherence. A sheet graft is solid layer of coverage which permits the best cosmetic outcome and is most preferred for hands or face (Hazini, Whitney & Wilhelmani, 2012).

Burns FLAPS (full thickness skin graft) what should be monitored with all skin grafts?

Monitoring viability of skin grafts include careful monitoring of vascular supply, capillary refill, color, and dermal bleeding.

Burns Orthotics More of than not, what is true when it come to splinting children with burns?

More often than not it is necessary to orthotic children immediately

Burns Orthotics Common positions of deformity include: (hand)

Neck (neck flexion) Axilla (adduction) Elbows (flexion) Wrists (flexion and extension) Digits (boutonnière, claw deformity)

Burns Pain management what is immersive virtual reality?

New evidence is emerging in the use of a new form of pain management known as immersive virtual reality Virtual reality is a type of cognitive distraction technique that has shown promising short term results as an effective analgesic in the treatment of burns.

Burns Coverage of more extensive hand and upper-extremity injuries

No single flap or reconstruction method is suitable for all occasions The simplest reconstruction in these cases is a vascularized free flap allowing early mobilization after 72 hours The groin flap can be pedicled or free and is excellent for the dorsal aspect of the forearm The latissimus dorsi muscle flap is the workhorse when small cavities need to be filled

Complications of Hand Burns The following complications can be associated with hand burns: Boutonniere deformity:

Occurs if central slip is burned - the lateral bands slide volar to the axis of the PIPJ and become flexors and the DIPJ goes into hyperextension. - If the extensor tendons are exposed at the PIPJ orthotic in full extension for 6-8 weeks - If the central slip is not completely destroyed - very gentle flexing can be performed to approximately 30 degrees.

Burns, Flaps, & Grafts Burn Classifications: Superficial (first Degree):

Occurs only in the epidermis and are fast healing injuries without permanent scarring or long term damage. Superficial burns are painful. Re-epithelialization begins within 48 hours. Superficial burns do NOT blister.

Burns Pain management Various treatment modalities which can assist in pain management are listed below:

Orthosis Paraffin Ultrasound Fluidotherapy Soft tissue mobilization Joint mobilization Relaxation training Wound care

Burns Orthotics Placing structures in a protected position is key for prevention of contractures.

Orthotic early to avoid, rather than having to correct, contractures Serial orthotics may be needed as edema decreases Use Kling® straps vs. straps in the early phases to prevent tourniquet effect from straps

Burns Orthotics What does orthotic wear schedule depend on?

Orthotic wearing schedule will depend on the amount of edema, ability of the patient to maintain AROM and proper positioning, and associated injuries to structures Ideally the patient will use the orthotic at night only and use the hand for functional tasks during the day. Multiple orthotic revisions may be required as the patient heals.

Burns EXERCISE/MOTION When is PROM incorporated into treatment?

PROM - is used after the inflammatory stage if limited motion has resulted. CPM can also be applied but remember this does not replace active motion. PROM is often needed to fight the antagonistic scar as it exceeds the patient's ability to move actively.

Burns Orthotics How should palmer burns be positioned?

Palmer burns are positioned with the wrist extended, MP's extended, IP's extended, digits abducted and thumb in abduction and extension. However, with the palmer burn it is usually more beneficial to alternate this orthotic with the safe position orthotic - this is especially true for circumferential burns. This orthosis is called a pan orthosis.

Burns Pain management What is key throughout the recovery process?

Patient education is key throughout recovery in all aspects of care.

Burns ROM PAMs

Physical agent modalities including paraffin are noted to be useful in elongating tissue when combined with sustained stretch during the application procedure. Skin integrity, stage of healing, intact sensation, and patient comfort are key considerations while applying heat. - Orthotic devices with the intention of mobilizing tissues are accomplished with the use of dynamic, serial, and static progressive orthotics.

Burns Custom Pressure Garments

Pressure garments are intended to flatten and smooth the appearance of scar tissue. Custom garments can cause notable shearing during application and removal and thus should be applied when skin is able to sustain pressure force of 25 mm Hg. According to literature, pressure is applied to increase collagen organization and decrease scar tissue formation. Special care must be applied when donning compression garments to eliminate shearing forces on healing tissue.

BG Use of non-perfumed moisturizers, cold packs, and antihistamines may alleviate persistent itching which is associated with burns. Another name for itching is?

Pruritus

Burns Flap Classifications - Vascular Random

Random - receive their blood supply from many vessels of the subdermal or subcutaneous plexus; ex: abdominal and contralateral arm. - This flap has not specific arteriorvenous supply

BG How does a burn wound heal if confined to the dermis or the epidermis?

Re-epithelialization

Burns, Flaps, & Grafts Burn Classifications: Superficial partial thickness (2nd Degree):

Reaches the upper dermis layer and can blister. Hair follicles are not involved. Healing takes place in 7-21 days with minimal or no scarring. Re-epithelialization begins within 10- 14 days with topical wound care. Visually, these burns appear to demonstrate blisters (intact or ruptured) and thin eschar. Burns in this region are painful as nerve endings reside in this dermal layer. Erythema and edema are also common.

Burns Wound Care Terms related to colors dictate the level of wound care. Wounds are classified as:

Red: Healthy, uninfected, beefy, budding, granulation tissue Yellow: Sloughing, pus, thick, creamy, clear yellow. Can be any color from creamy ivory to canary yellow. Black: Necrotic tissue. Can be dark brown to gray black in color.

BG A burn contracture of the first web space results in what deficit?

Reduction of thumb abduction and opposition

Burns Wound Care What is WVNP?

Research has shown wound vac negative pressure (WVNP) has been effective in increasing the healing process in subjects with full thickness burns. Negative pressure therapy may help increase the viability of adjacent tissue by stimulating angiogenesis.

BG What is the principle behind tissue engineering?

Researchers are developing products to serve as dermal substitutes for wound healing. "Integra" is a product made of collagen-based wound repair, bio-material which has been used for the treatment of burns.

Burns Flap Classification by Technique

Rotational Transitional Advancement (no rotation is suited for coverage of a thumb tip amputation) Direct Island (axial pattern) Moberg (used with large digital defects instead of V-Y advancement) V to Y advancement (lateral V-Y and volar V-Y) Cross-finger (random pattern) Thenar flaps (ideal for reconstruction of major distal phalangeal finger amputations). Advantages include exact tissue match. A major complication is a flexion contracture in the recipient digit.

BG How is the extent and the depth of a burn wound assessed?

Rule of Nines

Burns Orthotics How should a dorsal burn be positioned?

Safe position orthotic used for dorsal burns - wrist extended, MP's flexed 70-80, IP's straight, and thumb abducted. This counteracts the burn claw hand deformity; it places the MP collateral ligaments on stretch and preserves the anatomical arches of the hand.

Burns Wound Care Terms related to drainage are below:

Sanguinous Bloody Serous Clear or yellow Purulent Pus Dark red Hematoma

Burns Surgical Intervention and Reconstruction Skin Grafts When does sensory recovery usually take place?

Sensory recovery post grafting can be noted as early as 5 weeks and can continue to improve for up to two years

Custom Pressure Garments Silicone inserts such as Otoform have been noted to improve what?

Silicone inserts such as Otoform have been noted to improve the appearance of scar tissue.

Burns FREE FLAP Pedicle Classification by Tissue

Skin Fascial Fascial cutaneous Muscle Muscle cutaneous Bone [Flaps can also be classified by method of transfer, destination, geometry, and tissue composition.]

Burns Surgical Intervention and Reconstruction Skin Grafts What is a skin graft?

Skin grafting is a surgical intervention to remove destroyed or necrotic tissue and provide a replacement of tissue with skin or skin substitute. Listed below are various types of grafts including split thickness grafts and full thickness grafts.

Burns FLAPS (full thickness skin graft) soft tissue contractures will occur during which stages of healing?

Soft tissue contracture will occur both in the fibroblastic and hyperplasia phase of healing. Initially, contracture occurs to bring the wound edges together. In the final (late) phases of a healing with a burn, scar contracture occurs, despite the wound healing. When comparing split and full thickness skin grafts, less of the secondary contracture occurs in the late phase.

Custom Pressure Garments What levels of pressure are considered therapeutic? What levels of pressure are considered to be harmful?

Some references have advocated that 5-15 MMHg is therapeutic, while others claim they must have 15MMHg to be effective. Generally, pressure between 20-30 Mg is recommended and acceptable. Pressure greater than 30-40 Hg is potentially harmful.

BG What is the name of the procedure of a partial thickness of skin that is surgically harvested from the same individual to whom it is applied?

Split thickness skin graft (STSG) STSG (autograft) is often chosen for full-thickness burns and sometimes partial-thickness burns.

Burns EXERCISE/MOTION What dictates the type of motion to be achieved during therapy?

Stage of injury and post-operative protocol will dictate the type of motion to be achieved (PROM, AROM/AAROM). Preventing joint deformity is key, including full thumb ROM to perform full opposition. Web spaces should be stretched to prevent contractures. Tendon glides, intrinsic /extrinsic stretching, and place and hold are typical exercises to promote full motion in the hand.

Burns Wound Care hyperbaric oxygen therapy (HBOT)

Studies have been able to support hyperbaric oxygen therapy HBOT as a method to increase the healing of split thickness grafts. HBOT is used by delivering 100% oxygen at pressures above one atmosphere to facilitate wound healing..

BG What is the advantage of a V-Y advancement flap for fingertip injuries?

The V-Y flap contains Meissner's corpuscles and restores some sensation.

BG Describe the cross finger flap.

The cross finger flap is a random pattern flap and designed to cover exposed tendon or bone. This flap has a high rate of success and most patients regain protective sensation with two-point discrimination of approximately 8 mm.

Burns Surgical Intervention and Reconstruction Skin Grafts Epidermis

The epidermis comprises about 5% of the thickness of the skin. The epidermis serves as a barrier. The dermis is the functional portion of the skin Epidermis - The outer protective waterproof layer - This is what the world sees - The color, texture, and deformities such as scar manifest here - It is constantly replenishing itself - It has no collagen fibers - It has little inherit tensile strength - Varies in depth depending on location

Burns FLAPS (full thickness skin graft) where are flaps primarily used?

The flap is primarily used for small defects on the palmer aspect of the hand. Flaps are harvested from the hypothenar eminence, medial aspect of the arm or groin. Hypothenar eminence grafts sites provide good sensibility and "fingerprint" of skin.

Burns FREE FLAP Pedicle

The part of the flap that provides the blood supply is termed the pedicle. All flaps have pedicles of varying types. A flap receives its blood supply from a source other than the tissue in which it is placed. The pedicle is the undivided portion of the flap with the vascular supply needed for the flap to survive.

Burns Post-operative Flap Management

The post-operative dressing is a dry gauze to absorb the flap's drainage The dressing maintains a position free from tension and eliminates pressure on the vascular pedicle A drain is inserted under the flap, allowing drainage by gravity to prevent hematoma formation - this is removed after 72 hours or it will be removed when drainage falls below 30ml for a 24 hour period While pedicle is in place, keep wounds clean and dry Orthotic applied - usually after 72 hours Orthotic is often dynamic to allow for early motion Elevate

Burns Orthotics What is the primary role of orthotics in burns?

The primary role of orthotics in burn management is to prevent contractures. Anti-deformity orthotic devices are constructed using custom-made low temperature thermoplastic and are ideal to suit the needs of each patient. When lack of time and/or cost considerations are factors, pre-fabricated orthotic devices can be applied. These orthotics may or may not be fabricated and applied over a dressing.

Burns Wound Care What is the purpose of dressing?

The purpose of dressing placed directly on the wound is to provide protection and prevent infection. Red wounds: Non-adhering contact layers such as Adaptive and Xeroform are often used. Yellow wounds (non-infected): Dressings which absorb fluid and encourage autolytic debridement are often used, i.e. hydrocolloid and hydrogel. Black wounds: Topical antibiotics help soften eschar, decrease bacteria and promote a moist environment. (ie: travase, elase)

Burns EXERCISE/MOTION Early pressure: About ordering compression gloves:

The therapist will need to order 2 gloves so that the patient will have a backup one while the other is being washed. Hand washing the PG will prevent the garment from breaking down so fast. New garments may need to be reordered every 2-3 months to ensure a proper fit as they can stretch out over time and edema changes may change final fit as wwell CLINICAL GEM: Pressure garments designed for greater pressure degrade faster than those with lower pressure.

Burns Specific Flaps to Review: Thenar flaps

Thenar flaps - This was first described in 1926. This is an excellent technique for reconstruction of major distal phalangeal finger amputations. The tissue match is exact. Major complication is the recipient finger getting a flexion contracture.

Burns can also be named by types:

Thermal Contact Electrical Chemical

Burns can also be described by type of injury as listed:

Thermal Traumatic Electrical Chemical Scald Contact Flame Radiation

Burns, Flaps, & Grafts Burn Classifications: Deep partial thickness (3rd degree):

These burns reach the deep layers of the dermis and are considered severe and painful. Because vascular integrity is disturbed, healing may be delayed as long as six weeks. Pressure sensation is intact; however, light touch is impaired. Grafts are often necessary to promote healing. Burns in this layer can cause deformities, hypertrophic scarring and contractures. Appearance: Absence of blisters, possibly moderate thick eschar, may appear white, waxy or charred - Immediate pain is less intense due to damage to superficial nerve endings at this depth.

Burns FLAPS (full thickness skin graft) tissue flaps are labeled specific to:

Tissue flaps are labeled specific to: layers of tissue mobilization technique vascular supply

BG What is the benefit of a surgical z-plasty?

To expand and elongate tissue surface undergoing surgical procedures.

BG TBSA stands for what?

Total burn surface area

Total burn surface area (TBSA)

Total burn surface area refers to the amount of body tissue damaged with the burn injury. This formula is a predictive tool to help the health care team understand the extent of injury. The rule of 9 is a standardized way to initially assess the severity of the burn injury. The upper extremity is rated 9% TBSA and the hand is 3%. A burn to the hand is usually not a life threatening issue, however the results can be life altering. Loss of hand function can lead to an impairment rating of 95% for the involved extremity and 57% of a whole person.

Custom Pressure Garments Where can transparent orthoses be utilized?

Transparent orthoses can be fabricated for facial burns.

Custom pressure garments Clinical gem: Are there alternatives for clients who need to wear a compression mask over their face?

Transparent silicone masks can be customized, allowing for facial features to be seen during mask wear.

Burns, Flaps, & Grafts Burn Classifications: How are burns classified?

Until recently, burn injuries were referred to as 1st, 2nd and 3rd degree burns. The current classification of burns is based on cellular response and is referred to as superficial, superficial partial thickness, deep partial thickness and full thickness burns.

Burns EXERCISE/MOTION Early pressure: Suggestions for pressure garments (PG):

Use zippers on fresh grafts Consider that palmer zippers may inhibit hand function Keep open fingertips if possible to encourage functional hand use Order web space inserts if there are web space concerns

Burns Surgical Intervention and Reconstruction Skin Grafts Post op

Usually left for 4-5 days post-operatively, unless there is a risk for infection. If a graft is lost it is usually the result of shear forces, fluid accumulation under the graft, tension, or purulence Early grafting is ideal. Immediate debridement and grafting is often possible After day 5 daily dressing changes are initiated Gentle AROM may begin by the 5th to 7th day post-op. Perform ROM with dressings off to prevent shearing forces Elevation is used to manage edema until compression is applied Whirlpool can be used to clean the wound and stimulate local circulation and facilitate wound healing Advise patients to avoid the sun for a minimum of six months post grafting to prevent permanent discoloration

Burns Specific Flaps to Review: Volar V-Y advancement flap

Volar V-Y advancement flap - this uses the volar surface of the pad to cover defects of the tip. This flap advances about 10 mm and provides excellent coverage.

Burns Wound Care How does WVNP increase angiogenesis?

WVNP is thought to increase angiogenesis by decreasing oxygen in the wound site and decreasing the ability for bacteria to grow, allowing optimal evacuation of excessive fluid. Application of this modality includes sealing the wound with a foam dressing while negative pressure is applied to the wound bed via tubing that is threaded through the dressing. IT also prevents shearing and can decrease the need for secondary grafting.

Burns Split Thickness Skin Graft (STSG) What do you need to watch out for early on?

Watch for hypertrophy and treat with early pressure and sustained stretch to minimize scar hypertrophy and scar tissue contractures. The severity of hypertrophy depends on the depth of the burn, area of burn (e.g. at joints contracture rate increases), length of time for healing, age, skin color and grafting.

Burns Causes of Skin Flap Failure:

Wound infection Systemic hypotension Tension on the graft Hematoma Cigarette smoking, (diminishes blood flow and limits the oxygen carrying capacity) Inadequate blood supply (most likely due to poor planning by the surgeon - vascular insufficiency) Insufficient arterial inflow (primary cause of flap failure) Longstanding poor general health Decreased cardio respiratory function Atherosclerosis

Burns Surgical Intervention and Reconstruction Skin Grafts The following criteria must be met for successful grafting to occur:

Wound surface must be viable - all nonliving tissue must be debrided All bleeding must be controlled or the graft will fail due to hematoma All granulating surfaces contain bacteria; however, contamination should be minimal The patient must be in stable condition before grafting

Burns Wound Care Wounds are evaluated in terms of:

Wounds are evaluated in terms of color, exudate, size, length and depth

BG What is the proper positioning for the anti-deformity orthotic?

Wrist extension 20-30 MP's at 70-90 and IP's in full extension Thumb in palmer abduction and slightly opposed Orthotics in this position helps overcome an imbalance of tendon forces which lead to deformity.

Burns Orthotics Clinical gem: Static orthotic is used mainly to counteract the deforming position of edema, to support the hand, and to maintain the joint alignment. Edema contributes to the classic burn hand deformity of:

Wrist in flexion MPJ in hyperextension IPJs in flexion Thumb adducted Flattening of the transverse palmar arch

Custom Pressure Garments Silicone Elastomer Sheeting works well when used in conjunction with:

coban wrapping

Burns Hydrotherapy

helps decrease pain, relaxes the hand, enables easier exercise due to increased buoyancy, increases patient cooperation, and can clean the wound. NOTE: whirlpools are not the first choice of treatment today; however, for teaching purposes we included the benefits of whirlpool treatment.

Burns Complications

· Infection · Thrombosis at the anastomosis sites · Hematoma formation · Donor-site morbidity · Tendon adhesions · Joint stiffness · Inadequate return of sensation

Burns Flaps most frequently used for fingertip and digital injuries

· V-Y flap - popularized by Atasoy and Kutler - used for finger tip injuries · Moberg advancement flap - for more extensive thumb volar tip loss · Neurovascular island pedicle flap from the dorsum of the index finger for the thumb · Thenar flap · Cross- finger - patient returns in 2-3 weeks for separation · Reversed cross-finger