Presentation on theme: "Positioning and Splinting for the Prevention of Contractures"— Presentation transcript:
1Positioning and Splinting for the Prevention of Contractures Burn RehabilitationPositioning and Splinting for the Prevention of ContracturesMichael A. Serghiou, OTRShriners Hospitals for Children
2INTRODUCTIONThe positioning of the burn patient is vital in bringing about the best functional outcomes in rehabilitation. It should begin immediately after the injury occurs and carried out until the scars from the last operative procedure are matured and all contractile forces cease to exist.
3INTRODUCTIONPositioning should be designed for the specific individual’s needs and be closely monitored and altered as the patient’s medical status changes. It should not compromise mobility and function as these will greatly affect the final functional outcome.
4INTRODUCTIONThe statement that “the position of comfort is the position most likely to lead into contractures” is applicable to every burn patient who has sustained a serious injury.
5Positioning Must Be Designed In A Way That It: Maintains ROMPromotes wound healingRelieves pressureProtects joints, exposedtendons and newgrafts/flapsReduces edemaMaintains joint alignmentMaintains tissues elongatedPrevents contractureformation
6When Positioning The Burn Patient The Therapist/Nurse Should Consider The Following: TBSADepth of the burnAssociated injuriesExposed tendons/jointsPatient’s post operative status
7Complications Resulting From Prolong Or Improper Positioning Include: Pressure ulcersNerve lesionsDecreased ROMJoint malalignment
9HEADAppropriate position: Elevation with shock blocks. 12 inches tall blocks may achieve 30 degrees elevation at the head of the bed.Special considerations: Foot board to prevent sliding down the bed when head elevated.Shock blocks are only used with regular beds.
10NECKAppropriate Position: Neck in midline with degrees of extension.Special Considerations: Intubated patients may be positioned in neutral or in slight extension in maintaining good airway.Neck flexion contractures can lead to major cosmetic deformities, ventilatory difficulties,problems with salivation, vocalization and in extreme cases dislocation of the mandible.
11NECK Short mattress supine Roll behind the neck Head strap Never use a pillow for positioning the neck or the head of a burn patient.
12SHOULDERAppropriate Position: 90 degrees abduction with degrees horizontal adduction and slight external rotation.Special considerations: Monitor radial pulse and reposition the arm frequently to avoid compression of the brachial plexus which may lead to a neuropathy.Look for sensory (tingling, numbness) or motor (weakness,paralysis) deficits.
13ELBOWAppropriate Position: Elbow in full extension with the forearm in neutral in slight supination. Avoid locking the elbow in extension.Special considerations: Although flexion is the functional position, limitations develop more frequently in this position.
14WRIST and HANDAppropriate Position: Wrist in 0-30 degrees extension, MCP joints in degrees flexion, IP joints in full extension. The thumb is positioned in a combination of palmar and radial abduction maintaining the first web space in a stretched position.Special Considerations: A dropped wrist not only leads to functional limitations, but can also cause compression to the median and ulnar nerves and disturb the venous return resulting in edema.
15WRIST and HANDExposed tendons and joints should be positioned in a splint at all times without exceptions. During dressing changes of the hand with exposed structures the splint may be briefly removed while the affected structures are manually supported. The splint should be reapplied immediately after the dressing is completed.
16HIPSAppropriate Position: Neutral rotation, degrees hip abduction and knee extension.Special Considerations: The combination of hip flexion and abduction tightness can lead to hip dislocation. In patients with NO ventilatory problems the prone position facilitates hip as well as knee extension.
17KNEES Appropriate Position: Full knee extension. Avoid locking the knee in full extension.Avoid elevation of the legs with knees unsupported.
18FOOT and ANKLEAppropriate Position: The ankle joint is positioned in neutral/90 degrees dorsiflexion with the use of a foot board or a splint.This position should be maintained while the patient is lying in the prone or supine position.Special Considerations:Plantar flexion and inversion lead to the equino varusdeformity.Hard surfaces encourage venous stasis and can causeheel decubiti.
19ORTHOTICS/SPLINTINGIntroduction: Orthotic and splinting devices are vital in burn rehabilitation as they are utilized throughout the patient’s recovery in obtaining appropriate positioning of the entire body.No matter how the therapist approaches splinting(materials, designs, application schedules) the goal is to bring about the best functional outcome at the completion of rehabilitation.
20ORTHOTICS/SPLINTINGIntroduction: The burn therapist must be aware of the anatomy and kinesiology of the body part to be splinted prior to fabricating a splint or an orthotic device.
21Splinting Definitions Static splint: Static or passive splints indicate that the affected joint or joints are to be immobilized or be movement restricted.Dynamic splint: A dynamic splint is one that achieves its effects by movement and force. “It is a form of manipulation”. It may use forces generated by the patient’s own muscles or externally imposed forces using rubber bands or springs.
22Orthotics and Splinting Devices are used to: Appropriately position a body partSupport,protect and immobilize jointsPrevent and/or correct deformityProtect new grafts and flapsMaintain and/or increase ROMAid in edema and pain reductionRemodel joint and tendon adhesions
23Orthotic and Splinting Devices are used to: Stabilize and/or position one or more joints enabling other joints to function correctlyAssist weak muscles to counteract the effects of gravityStrengthen weak muscles by having the patients exercise against springs or rubber bands
24Splints and Orthotics should: Not cause painBe functionalCosmetically appealingBe easy to apply and removeBe light weight and low profileBe of appropriate materialsAllow for ventilation
25Mechanical Principles of Splinting Pressure; Reduce pressure by increasing the area of application.Mechanical Advantage (MA); Control parallel forces by increasing the MA.Use optimal rotational forces when mobilizing a joint by dynamic traction.Dynamic traction should be applied at a 90 degree angle.Torque; Consider the torque effect on a joint.
26Mechanical Principles of Splinting Stabilize proximal normal joints to correctly mobilize distal affected joints.Consider the effects of reciprocal parallel forces when designing splints and placing straps.Increase splint strength by contouring the material’s surfaces.Eliminate friction and splint migration.
31HEADMOUNTH SPLINTS-Static -Dynamic Special Considerations -decreased vertical or horizontal opening -progressive stretching -drooling
32NECK Soft neck collar Anterior neck conformer (open,closed) Lateral neck conformer;Torticollis splintPosterior neck collar with halo strapSpecial Considerations - neck contractures make for difficultintubation in case of an emergency.
33AXILLA/SHOULDER Axillary Pads Airplane Splints custom made SCOI Special Considerations avoid stress on the brachial plexus
36HAND Static - burn hand splint - stax splint (c-bar) - ”sandwich splint”- resting pan splint- thumb web spacer(c-bar)- digital gutter splint- stax splint- Murphy rings- figure 8 digital splint- dorsal hand splint
37HANDDynamic - MCP/IP joint flexion/extension splints - thumb outrigger - knuckle benders -spring flexion/extension splintsSpecial Considerations -maintain angle of pull at 90 degrees
40ANKLE/FOOTStatic - Multipodus Splint System - dorsiflexion splint - plantarflexion splint - AFODynamic - AFO made by the orthotist
41Serial Casting Provides a prolong sustained stretch A fast, relatively inexpensive method of correcting burn scar contracturesFlexion contractures of over 30 degrees respond well to castingProvides circumferential evenly distributed pressureIt offers a successful alternative to dynamic splinting when patient compliance is an issue i.e. pediatrics