Positioning and Splinting for the Prevention of Contractures Burn Rehabilitation Positioning and Splinting for the Prevention of Contractures Michael A. Serghiou, OTR Shriners Hospitals for Children mserghiou@shrinenet.org

INTRODUCTION The 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.

INTRODUCTION Positioning 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.

INTRODUCTION The 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.

Positioning Must Be Designed In A Way That It: Maintains ROM Promotes wound healing Relieves pressure Protects joints, exposed tendons and new grafts/flaps Reduces edema Maintains joint alignment Maintains tissues elongated Prevents contracture formation

When Positioning The Burn Patient The Therapist/Nurse Should Consider The Following: TBSA Depth of the burn Associated injuries Exposed tendons/joints Patient’s post operative status

Complications Resulting From Prolong Or Improper Positioning Include: Pressure ulcers Nerve lesions Decreased ROM Joint malalignment

POSITIONING FOR THE ENTIRE BODY

HEAD Appropriate 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.

NECK Appropriate Position: Neck in midline with 10-15 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.

NECK Short mattress supine Roll behind the neck Head strap Never use a pillow for positioning the neck or the head of a burn patient.

SHOULDER Appropriate Position: 90 degrees abduction with 15-20 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.

ELBOW Appropriate 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.

WRIST and HAND Appropriate Position: Wrist in 0-30 degrees extension, MCP joints in 70-90 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.

WRIST and HAND Exposed 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.

HIPS Appropriate Position: Neutral rotation, 10-15 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.

KNEES Appropriate Position: Full knee extension. Avoid locking the knee in full extension. Avoid elevation of the legs with knees unsupported.

FOOT and ANKLE Appropriate 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 varus deformity. Hard surfaces encourage venous stasis and can cause heel decubiti.

ORTHOTICS/SPLINTING Introduction: 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.

ORTHOTICS/SPLINTING Introduction: 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.

Splinting 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.

Orthotics and Splinting Devices are used to: Appropriately position a body part Support,protect and immobilize joints Prevent and/or correct deformity Protect new grafts and flaps Maintain and/or increase ROM Aid in edema and pain reduction Remodel joint and tendon adhesions

Orthotic and Splinting Devices are used to: Stabilize and/or position one or more joints enabling other joints to function correctly Assist weak muscles to counteract the effects of gravity Strengthen weak muscles by having the patients exercise against springs or rubber bands

Splints and Orthotics should: Not cause pain Be functional Cosmetically appealing Be easy to apply and remove Be light weight and low profile Be of appropriate materials Allow for ventilation

Mechanical 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.

Mechanical 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.

SPLINTING and POSITIONING for the ENTIRE BODY

HEAD FACE a) Transparent Face Mask (UVEX) - negative and positive molds required - prevents/ corrects scar hypertrophy - cosmetically appealing b) Opaque Face Mask - negative mold only - prevents scar hypertrophy c) Silicone Elastomer Face Mask - negative and positive molds required - prevents/ corrects scar hypertrophy

HEAD NOSE SPLINTS - nasal obturators - secure obturator to face mask or consider the “mustache nostril splint” - serial splinting

HEAD EAR SPLINTS -Internal; ear obturator -External; “oyster” splint

HEAD MOUNTH SPLINTS -Static -Dynamic Special Considerations -decreased vertical or horizontal opening -progressive stretching -drooling

NECK Soft neck collar Anterior neck conformer (open,closed) Lateral neck conformer;Torticollis splint Posterior neck collar with halo strap Special Considerations - neck contractures make for difficult intubation in case of an emergency.

AXILLA/SHOULDER Axillary Pads Airplane Splints -custom made -SCOI Special Considerations -avoid stress on the brachial plexus

ELBOW Static - anterior elbow conformer - 3-point extension Dynamic -flexion or extension

WRIST Static - wrist cock-up; volar/dorsal splint component - palmar wrist splint with a thumb component - wrist deviation splints Dynamic - wrist flexion/extension/deviation

HAND 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

HAND Dynamic - MCP/IP joint flexion/extension splints - thumb outrigger - knuckle benders -spring flexion/extension splints Special Considerations -maintain angle of pull at 90 degrees

HIP Hip spica 3-point extension hip splint

KNEE Static - posterior knee conformer - 3-point extension Dynamic -infrequently utilized

ANKLE/FOOT Static - Multipodus Splint System - dorsiflexion splint - plantarflexion splint - AFO Dynamic - AFO made by the orthotist

Serial Casting Provides a prolong sustained stretch A fast, relatively inexpensive method of correcting burn scar contractures Flexion contractures of over 30 degrees respond well to casting Provides circumferential evenly distributed pressure It offers a successful alternative to dynamic splinting when patient compliance is an issue i.e. pediatrics