Splinting, Positioning, Edema, and Scar Management After Burn Injury

Abstract

To achieve optimal function and independence, an individual relies on the combined use of a number of treatment modalities available to therapists (Parry and Esselman, J Burn Care Res 32:458–467, 2011; Simons et al., J Burn Care Rehabil, 24(5), 323–335, 2003). This chapter provides an overview of (1) the classification and epidemiology of burn injury and burn scarring, and (2) intervention modalities that aim to minimize impairment to body structures and body functions after burn injury, by using positioning and splinting, and edema and scar management.

After burn injury, the ultimate goal is to assist an individual to achieve optimal function and independence.

Appendices

The Case Study of Harry

Keywords

Cicatrix, pediatric burn, rehabilitation

Introduction

The presentation of this case aims to highlight (a) the role of OT in managing burn scarring: scar management, exercises, adjustment to altered body image, education, and (b) the competing priorities that often emerge in the OT management of scarring postburn and for families where caregivers work, have social and recreational priorities, and look after other children.

The student’s tasks include:

• 1. To identify areas at risk of contracture postburn due to scarring.

• 2. To outline both individual and family factors that must be considered in OT treatment.

• 3. To outline a scar management regimen for Harry.

As a starting point, the students should use the following references to gather background information:

• 1. Parry I, Esselman PC (2011) Clinical competencies for burn rehabilitation therapists. J Burn Care Res 32:458–467

• 1. Rappoport K, Muller R, Flores-Mir C (2008) Dental and skeletal changes during pressure garment use in facial burns: a systematic review. Burns 34(1):18–23

• 2. Rayatt S, Subramaniyan V, Smith G (2006) Audit of reactions to topical silicon used in the management of hypertrophic scars. Burns 32(5):653–654

• 3. Rosenberg L, Lawrence JW, Rosenberg M, Fauerbach JA, Blakeney PE (2012) Psychosocial recovery and reintegration of patients with burn injuries. In: Herndon DN (ed) Total burn care, 4th edn. Saunders, pp 743–753.e4

• 4. Serghiou MA, Ott S, Whitehead C, Cowan A, McEntire S, Suman OE (2012) Comprehensive rehabilitation of the burn patient. In: Herndon DN (ed) Total burn care, 4th edn. Saunders, pp 517–549.e4

Overview of the Content

Major goal of the actual interventions are:

• 1. To support a person’s adjustment postburn injury within the context of their biological, psychological, social, and environmental needs.

• 2. To minimize the impact of body impairments on function.

Learning objectives are:

The student will

• 1. Be aware of body structures at risk of impairment postburn injury from scarring and burns scar treatments

• 2. Be able to propose a scar management regimen postburn injury and consider differences between a day regimen and an overnight regimen

• 3. Consider individual and family factors when prescribing a scar management regimen postburn injury

The Background History of the Clinical Case Study

Personal Data

Harry is a 10-year-old boy. He is the eldest of four boys, burned while making a fire bomb in his backyard. His family live three hours’ drive away from the closest OT department, in an area where the temperature is above 30 °C (86 °F) for most of the year. Prior to Harry’s burns, he loved playing cricket and soccer.

Harry’s mother who works as an administration officer has taken 3 months off work since Harry was discharged home. She has found that Harry’s scar management regime and exercises take one and a half hours to supervise and assist with in the morning as well as in the evening. He doesn’t think he will be able to play cricket this season as he finds being outside in the sun exacerbates his itch (which he rates as 7 out of 10 on a numerical rating scale on his worst days). Harry’s dad now prepares evening meals and takes Harry’s brothers to sport training and weekend games.

Medical Diagnoses

Harry sustained deep partial-thickness burns to most of his face, neck, and upper torso with involvement of both axillae, his mandible, nose, and mouth. He also suffers from eczema.

Reason for Seeking Occupational Therapy

Current Circumstances

Harry has been home 2 weeks since being discharged from hospital. Prior to discharge, the OT fitted him with a custom-made face mask and vest (pressure garments), a TFO (a facial orthotic) and neck extension roll. Harry’s neck, chin, upper torso, and axillae have signs of hypertrophic scarring with scar bands obvious in these areas although movement is only affected in his right shoulder. Harry has not yet returned to school as he still gets very tired during the day.

Occupational Performance Issues

Harry was provided with silicone sheets to apply daily to areas not affected by eczema. Prior to discharge, the OT educated Harry and his mother regarding the potential side effects of scar management products. The OT discussed return to school and dealing with the reactions of other children prior to discharge. The OT linked in via the Internet (Skype), when Harry’s mother talked to his class about Harry’s experiences in hospital. Harry still has an open wound below his ear that requires a new dressing each day. The dressing is worn beneath his pressure garment. Harry’s exercise and splinting regime consists of: (a) a home exercise program completed three times daily focusing on range of motion, strengthening, and endurance (provided by physiotherapist), (b) an axillae splint worn on the right side at night, and (c) a mouthguard worn at night. His creams take 30 min to put on after his bath each day and he only wears his TFO between meals as it is too restrictive to eat while in situ.

When questioned by the OT about her concerns, Harry’s mum indicates she is worried about whether the look of his scars will bother him in the future and whether they will affect his relationship with others as he enters his teenage years. She also expresses concern that the bright outlook she tries to convey to Harry might be overly optimistic.

The Student’s Report

The following guiding questions have been identified in developing possible solutions to Harry’s scar management dilemmas and supporting his transition back to normal roles including being a student and brother/son.

Questions

• 1. What are the indications for use of a compression garment, silicone, and splinting program with Harry?

• 2. What wearing regime would you prescribe for his pressure garments and TFO?

• 3. Why was Harry prescribed silicone sheets for wear only in areas not affected by eczema?

• 4. What are the musculoskeletal risks of using a compression garment on the face and would you minimize these risks for Harry?

• 5. How would you consider family factors that are likely to impact on the implementation of Harry’s scar management regimen?