Musculoskeletal management of the severely burned child J.R. BIRCH, MD, FRCS[C]; B. EAKINS, CAOT;. J. GOSEN;* S. GREEN, MCSP; M. MORTON, RN
Aggressive management of severe burns minimizes contractures and helps to maintain muscle tone, joint function and psychological well-being. The positioning, activity and exercise programs, splinting and bandaging, and skin care of burned children car.led out by the burns team at the Hospital for Sick Children, Toronto is outlined. Un traitement agressif des brfllures graves minimise les contractures et contribue au maintien du tonus musculaire, au fonctionnement des articulations et au bien-Stre psychologique. On d6crit Ia mise en position, les programmes d'actlvit6 et d'exercice, l'usage de gouttieres et de pansements et les soins de Ia poau pour les enfants brOl6s pratiquds par l'equipe de soins aux brOl6s au Hospital for Sick Children de Toronto. In our experience most health professionals and parents tend to overprotect the burned child, unwittingly increasing or even causing deformity and handicapping the child psychologically. In referring these patients for follow-up care we have encountered a dearth of knowledge, especially in relation to the effects of immobility. Many patients referred to us have contractures due to a fear of using burned limbs, and such problems as leg contracture resulting from the application of a heel-lift when full extension of the leg should have been encouraged. Proper musculoskeletal management of burned children should minimize contractures and maintain optimal joint function while allowing near-normal healing of burn wounds and psychological development. In children with burns of over 30% of their body surface area, this involves positioning, splinting and exercises. 1-4 This article outlines the musculoskeletal management carried out by the burns team (nurses, occupational therapist, orthotist and physiotherapist) at the Hospital for Sick Children, Toronto. These guidelines will probably be most useful for those who are called upon only occasionally to treat severely burned patients or are responsible for coordinating their care. From the burns unit (plastic surgery division), the Hospital for Sick Children, Toronto 9Orthotist Reprint requests to: Dr. JR. Birch, Department of surgery (plastic surgery division), The Hospital for Sick Children, 555 University Ave., Toronto, ON M5G 1X8
Edematous stage
After a burn there is severe swelling for about 5 days, when the patient may have intravenous and urinary catheters and possibly a central-venouspressure line in place. The burn is covered with silver sulfadiazine cream and left exposed.
halation injury is suspected, four times daily. For this, foam rubber is placed
Positioning
The patient is nursed on a foam pad (Table I), and if on a circle bed is tilted frequently. Early correct positioning decreases contractures:5'6 rounded shoulders, adducted arms and flexed elbows, wrists, hips and knees are avoided. Special attention is paid to the hands2'7'9 (Fig. 1) and ankles,9 whether the patient is on his back (Fig. 2) or side (Fig. 3). Exercising Chest: Frequent deep breathing and coughing is encouraged. Postural draining is performed once daily or, if bronchial secretions are copious or in-
FIG. 2-Position on back: (a) neck in extension (no pillows, but small roll under neck); (b) shoulders abducted to 90, with 20 flexion to prevent shoulder subluxation; (c) elbows in extension; (d) hands (see Fig. 1); (e) hips in extension, with 150 abduction and neutral rotation; (f) knees in extension; and (g) ankles in 90 dorsiflexion (neutral position), maintained by footboard.
FIG. 1-Above: hand position. Hands are covered with silver sulfadiazine cream and bandaged into isoprene splints to maintain (a) wrists in 15 extension, (b) metacarpophalangeal (MP) joints in 60 flexion, (c) interphalangeal (IP) joints in extension to prevent buffonhole deformity from strain on the burn-weakened extensor tendon, (d) thumb abduction and opposition rotation and (e) transverse palmar arch. Splints must be applied carefully to avoid distal slippage, which would extend the MP joints and flex the IP joints. In very small children with edematous hands it may be impossible to maintain the above position; splinting with IP and MP joints in extension is a practical compromise. Below: isoprene splint. Maintains (f) width across region of MP joints and (g) length from thumb web to fingertips. CMA JOURNAL/SEPTEMBER 18, 1976/VOL. 115 533
seated in a chair while the bed is changed; the brief change in position improves lung function and provides a psychological lift.
PLASTIC FOAM PILLOW
PLASTIC Ft.AM PILLOW
SLING
d
FIG. 3-Position on side: (a) neck in extension, with small pad under head to maintain neutral neck rotation and side flexion; (b) shoulders (lowermost arm flexed 90; uppermost arm supported at 90 flexion by hanging sling); (c) elbows in extension; (d) hands (see Fig. 1); (e) hips in as much extension as possible, with uppermost leg supported on foam pad; (f) knees in extension; and (g) ankles at 90 dorsiflexion (neutral position).
on the chest wall and the chest is clapped for 5 minutes in each of six positions. Inhalations of a moist bronchodilating mist may be given at the same time. Vital capacity (VC) and tidal volume (VT) are measured; if VC is less than VT x 2.5, escharotomy of a circumferential burn is considered. Limbs: Active movement is encour-
Later pregrafting stage When the swelling has subsided the burned skin forms a thick, hard eschar; this separates spontaneously or is removed to allow skin grafting. During this stage the patient is bathed one to three times daily, after which the burns are covered with silver sulfadiazine cream and left exposed. Positioning The positioning used in the edematoLls stage is maintained, but turning frequency is reduced to once every 2 hours. Isoprene splints can be used for the neck (Fig. 4), axilla (Fig. 5), elbows (Fig. 6), legs (Figs. 6 and 7) and hands (Fig. 1)." Exercising The exercise routine is increased to include sitting, walking and occupa-
aged to help overcome the patient's fear of using the burned limb. Active or assisted active movements of joints through as full a range of movement as possible and isometric exercises for large-muscle groups are done 10 times each, 3 times daily.2'5"0 Children too young to cooperate are subjected to gentle passive movements. Patients are
FIG. 4-Neck splint. Isoprene is softened in hot water (77C), dried with a towel and cooled slightly. It is applied directly to the neck, spreading from the centre outward to conform snugly but with the edges slightly flared. The cooling splint is held in place for 10 to 15 minutes, then removed for the attachment of Velcro straps with rapid rivets.
534 CMA JOURNAL/SEPTEMBER 18, 1976/VOL. 115
tional therapy. Positioning and activity are balanced to ensure maintenance of movement and avoid contractures. Hand care
Superficially burned hands are allowed free movement during the day but are splinted at night; deeply burned hands are splinted constantly except during exercise periods. Forced finger flexion is avoided to protect damage to extensor tendons from strain and rupture. Full mobilization begins when the dorsal surfaces of the fingers are healed. Grafting and early postgrafting stage This stage extends from the skin
grafting operation to about 14 days postoperatively. During the first 5 to 10 days the grafted area is immobilized in a dressing or restrained and left exposed to allow the graft to "take". Careful splinting is continued between exercise periods to prevent contractures. Splints can be worn directly or over light dressings on ulcerated areas but must be removed several times daily for cleaning of the ulcer and splint. Positioning FIG. 5-Axilla splint. After softening in hot water and drying, isoprene is applied directly to axilla, arm and chest, with arm abducted to 1100. A reinforcing isoprene strip (a) and aluminum rod (b) can be bonded to the splint, using carbon tetrachloride and rivets. Velcro strapping (c) is riveted on for fixation.
Neck: The neck is held in extension with a splinted dressing or a roll behind the neck and sandbags on either side of the head to prevent rotation. When the graft has taken (usually after about 2 weeks) a conforming splint (Fig. 4) is applied to avoid contracture.
Chest: The shoulders are held back; a small roll or pad between the shoulder blades helps to prevent contracture pulling the shoulders forward. Arms: The arms are held in extension by a plaster or isoprene splint in the dressing until the graft has taken, and then by an extension splint (Fig. 6). Legs: The legs are held in extension in the same way as the arms or by a rigid isoprene boot splint, which can be extended upward to immobilize the knee, as shown in Fig. 7. Exercising
A week to 10 days after grafting, gentle active and passive exercises are begun, often in the bath. Stretching exercises are stressed to avoid contracture. Late (stable graft) stage This stage begins 2 weeks after grafting and lasts until burn scars lose their red induration and become mature. Since the danger of contracture is maximal 6 to 12 weeks after grafting, restoration of full function is sought during this period. Continuous pressure and conforming splints help prevent and correct red
.1
OVERLAP
ANKLE HELD AT 900
ANTERIOR WIDTH OF FOOT .
DISTANCE FROM LOWER 1/3 OF CALF TO 1' ABOVE GREAT TOE
1/2 CIRCUMFERENCE OF LOWER 1/3 OF CALF
FIG. 6-Splints for dynamic extension of knees and elbows. Tensor bandages are wrapped around side-bars of splint at knee or elbow, pulling joint into extension, while isoprene pads at ends of bars hold proximal and distal portions of limb in position.
FIG. 7-Boot splint. Isoprene is softened in hot water, dried and applied to postenor surface of ankle. It is folded on itself at the sides of the ankle and when cooled is maintained in position by tensor bandaging or Velcro straps.
CMA JOURNAL/SEPTEMBER 18, 1976/VOL. 115 535
(immature) hypertrophic scars and contractures but have no effect on mature white or pigmented scars and scar contractures.'214 Constant pressure is best maintained on healed burn scars by the following measures: 1. Tensor bandages on limbs, applied over the burn scar and, if distal swelling occurs, distally to the digits. 2. Elastic pressure suits. These washable suits (Table I) are tailored to fit any area of the body. They are usually ordered for delivery just before the patient's discharge from hospital. 3. Rigid foam pressure face-mask (Table I). The mask is fabricated by the orthotist or physiotherapist, to be worn under an elastic pressure suit for the head. The suit applies pressure to the mask, which distributes it evenly over the face. 4. Conforming splints. Constant pressure is usually applied night and day for about 3 months and then only at night for another 3 months. If contractures begin to develop, splints must be worn for longer periods. Burn scars and grafts are lubricated twice daily with lanolin cream, petroleum jelly or bath oil, or a combination. Residual areas of ulceration can be covered with gauze dressings or simply with antimicrobial cream, and are cleansed two or three times daily. Areas of potential contracture are splinted with isoprene splints from about 2 weeks after grafting until the scar has matured. Splints are usually worn continuously (except for occupational therapy, physiotherapy and washing) for 3 months and then only at night for a further 3 months; they are checked and remodelled or remade as needed to conform to the changing skin surfaces as the scars mature. Positioning Face: A rigid foam face-mask is worn under an elastic pressure suit for the head to maintain facial shape and avoid contractures. Neck: Neutral rotation and moderate extension are held with a snugly fitting, neck-conforming splint (Fig. 4) designed to elevate the chin and reduce the neck circumference. If ulceration develops under the chin or on the upper part of the chest, frequent splint removal and cleansing are instituted or the patient temporarily wears an elastic pressure suit for the neck. Splinting is particularly important for the neck: without it severe contractures may develop within a few days. Axillae: The arms are held in moderate abduction with slight flexion. Contracture of mild to moderate axillary scars can be prevented by the
application of foam pads kept in place with a figure-of-eight tensor bandage. If the axillae are severely burned a conforming splint is necessary (Fig. 5). Elbows: The elbows are held in extension by a dynamic splint (Fig. 6), except during therapy and eating, for the first 2 weeks, and then at night and as required to prevent contracture. Hands: The metacarpophalangeal joints are kept in flexion and the interphalangeal joints in extension. A conforming hand splint (Fig. 1) is worn continuously except during therapy for the first 2 weeks, and then only when the hands are not being actively used. The hand is tensor-bandaged into the splint. Specially designed splints are used to prevent specific deformities (for example, with plastic tubing held tightly in the web spaces by elastic bands to prevent burn-scar syndactyly) and dynamic splints are used to increase finger or wrist extension while allowing use of the hand. Hips: The hips are kept in extension, with the patient lying prone, for half an hour three times a day. Sandbags can be placed on the knees while the patient is supine. Knees: The knees are kept in extension (as for the elbows) and splinted (Figs. 6 and 7). Feet: Ankles and toes are kept in neutral position in an isoprene boot with tensor bandaging over padding on the dorsal toe surfaces. Exercising Exercises through a full range of movement are continued daily to ensure that no contractures develop. Walking with tensor bandages applied to the legs is begun 2 weeks after legburn grafting. Sitting for long periods is avoided because it encourages hip and knee flexion contractures, and a wheelchair is not used. A program of gross motor activity is instituted, using large balls, skate boards and bicycles, to encourage normal whole-body movements; swimming is especially helpful. Independence in dressing, feeding and personal hygiene is encouraged. Instruction of parents in home care
tive such as methdilazine hydrochloride, cyproheptadine hydrochloride or trimeprazine tartrate is prescribed. Excellent musculoskeletal management in hospital may be to no avail if problems encountered by the patient after his return home lead to poor positioning and reduced movement. We find it imperative to maintain close contact with the parents and patient and other health professionals responsible for care; burn scars are constantly evolving, particularly in growing children, and splints and pressure appliances must be evaluated frequently and adopted whenever required. A firm approach is often necessary to ensure that splints are worn optimally. Parents must be counselled against overprotecting the patient and instructed that it is better to lose a small piece of skin or get a blister while playing than not to engage in sports at all. The help of an interested social worker is extremely beneficial in coordinating the burned child's return to his community. We thank the medical publications department for help with the manuscript, and the visual education department, The Hospital for Sick Children. References 1. DOBBS ER, CURRERI PW: Bums: analysis of results of physical therapy in 681 patients. J Trauma 12: 242, 1972 2. EVANS EB, LARSON
DL, ABSTON S, et al:
Prevention and correction of deformity after severe burns. Surg Clin North Am 50: 1361, 1970
3. GOLDBERG RT: Rehabilitation of the burn patient. Rehabil Lit 35: 73, 1974 4. KOEPKE GH: The role of physical medicine in the treatment of burns. Sung Clin North Am 50: 1385, 1970 5. EVANS EB: Orthopedic measures in the treatment of severe burns. J Bone Joint Surg [Am] 48A: 643, 1966 6. EVANS EB, LARSON DL, YATES 5: Preservation and restoration of joint function in patients with severe burns. JAMA 204: 843, 1968 7. LARSON DL, WOFFORD BH, EVANS EB, et al: Repair of the boutonniere deformity of the burned hand. I Trauma 10: 481, 1970 8. TAN IGAWA MC, O'DONNELL OK, GRAHAM PL: The burned hand: a physical therapy
protocol. Phys Ther 54: 953, 1974
9. HEIMBLrRGER RA, MARTEN E, LARSON DL, et al: Burned feet in children, acute and reconstructive care. Am J 5mg 125: 575, 1973
10. JAEGER DL: Maintenance of function of the burn patient. Phys Ther 52: 627, 1972
Before the child goes home he and his parents are instructed in (a) rangeof-movement exercises, (b) splint application and wearing times, (c) dressings, (d) increasing independence in routine activities, (e) sports participation, (f) schooling (as soon as possible, in a routine as normal as possible) and (g) management of itchy, dry skin by cool baths and the application of bath oil. The need for light, cool clothing is stressed and an antihistamine seda-
536 CMA JOURNAL/SEPTEMBER 18, 1976/VOL. 115
11. WILLIs B: A follow-up. The use of Orthoplast isoprene splints in the treatment of the acutely burned child. An, I Occup Ther 24: 187, 1970 12. FUJIMoRI R, HIRAMOTO M, OFuJI 5: Sponge fixation method for treatment of early scars.
Plast Reconstr Surg 42: 322, 1968
13. LARSON DL, ABsToN 5, EVANS EB, et al:
Techniques for decreasing scar formation and contractures in the burned patient. I Trauma 11: 807, 1971
14. WILLIs B: The use of Orthoplast isoprene splints in the treatment of the acutely burned child: preliminary report. Am I Occup Ther 23: 57, 1969
Aggressive management of severe burns minimizes contractures and helps to maintain muscle tone, joint function and psychological well-being. The positioning, activity and exercise programs, splinting and bandaging, and skin care of burned children car.led out by the burns team at the Hospital for Sick Children, Toronto is outlined. Un traitement agressif des brfllures graves minimise les contractures et contribue au maintien du tonus musculaire, au fonctionnement des articulations et au bien-Stre psychologique. On d6crit Ia mise en position, les programmes d'actlvit6 et d'exercice, l'usage de gouttieres et de pansements et les soins de Ia poau pour les enfants brOl6s pratiquds par l'equipe de soins aux brOl6s au Hospital for Sick Children de Toronto. In our experience most health professionals and parents tend to overprotect the burned child, unwittingly increasing or even causing deformity and handicapping the child psychologically. In referring these patients for follow-up care we have encountered a dearth of knowledge, especially in relation to the effects of immobility. Many patients referred to us have contractures due to a fear of using burned limbs, and such problems as leg contracture resulting from the application of a heel-lift when full extension of the leg should have been encouraged. Proper musculoskeletal management of burned children should minimize contractures and maintain optimal joint function while allowing near-normal healing of burn wounds and psychological development. In children with burns of over 30% of their body surface area, this involves positioning, splinting and exercises. 1-4 This article outlines the musculoskeletal management carried out by the burns team (nurses, occupational therapist, orthotist and physiotherapist) at the Hospital for Sick Children, Toronto. These guidelines will probably be most useful for those who are called upon only occasionally to treat severely burned patients or are responsible for coordinating their care. From the burns unit (plastic surgery division), the Hospital for Sick Children, Toronto 9Orthotist Reprint requests to: Dr. JR. Birch, Department of surgery (plastic surgery division), The Hospital for Sick Children, 555 University Ave., Toronto, ON M5G 1X8
Edematous stage
After a burn there is severe swelling for about 5 days, when the patient may have intravenous and urinary catheters and possibly a central-venouspressure line in place. The burn is covered with silver sulfadiazine cream and left exposed.
halation injury is suspected, four times daily. For this, foam rubber is placed
Positioning
The patient is nursed on a foam pad (Table I), and if on a circle bed is tilted frequently. Early correct positioning decreases contractures:5'6 rounded shoulders, adducted arms and flexed elbows, wrists, hips and knees are avoided. Special attention is paid to the hands2'7'9 (Fig. 1) and ankles,9 whether the patient is on his back (Fig. 2) or side (Fig. 3). Exercising Chest: Frequent deep breathing and coughing is encouraged. Postural draining is performed once daily or, if bronchial secretions are copious or in-
FIG. 2-Position on back: (a) neck in extension (no pillows, but small roll under neck); (b) shoulders abducted to 90, with 20 flexion to prevent shoulder subluxation; (c) elbows in extension; (d) hands (see Fig. 1); (e) hips in extension, with 150 abduction and neutral rotation; (f) knees in extension; and (g) ankles in 90 dorsiflexion (neutral position), maintained by footboard.
FIG. 1-Above: hand position. Hands are covered with silver sulfadiazine cream and bandaged into isoprene splints to maintain (a) wrists in 15 extension, (b) metacarpophalangeal (MP) joints in 60 flexion, (c) interphalangeal (IP) joints in extension to prevent buffonhole deformity from strain on the burn-weakened extensor tendon, (d) thumb abduction and opposition rotation and (e) transverse palmar arch. Splints must be applied carefully to avoid distal slippage, which would extend the MP joints and flex the IP joints. In very small children with edematous hands it may be impossible to maintain the above position; splinting with IP and MP joints in extension is a practical compromise. Below: isoprene splint. Maintains (f) width across region of MP joints and (g) length from thumb web to fingertips. CMA JOURNAL/SEPTEMBER 18, 1976/VOL. 115 533
seated in a chair while the bed is changed; the brief change in position improves lung function and provides a psychological lift.
PLASTIC FOAM PILLOW
PLASTIC Ft.AM PILLOW
SLING
d
FIG. 3-Position on side: (a) neck in extension, with small pad under head to maintain neutral neck rotation and side flexion; (b) shoulders (lowermost arm flexed 90; uppermost arm supported at 90 flexion by hanging sling); (c) elbows in extension; (d) hands (see Fig. 1); (e) hips in as much extension as possible, with uppermost leg supported on foam pad; (f) knees in extension; and (g) ankles at 90 dorsiflexion (neutral position).
on the chest wall and the chest is clapped for 5 minutes in each of six positions. Inhalations of a moist bronchodilating mist may be given at the same time. Vital capacity (VC) and tidal volume (VT) are measured; if VC is less than VT x 2.5, escharotomy of a circumferential burn is considered. Limbs: Active movement is encour-
Later pregrafting stage When the swelling has subsided the burned skin forms a thick, hard eschar; this separates spontaneously or is removed to allow skin grafting. During this stage the patient is bathed one to three times daily, after which the burns are covered with silver sulfadiazine cream and left exposed. Positioning The positioning used in the edematoLls stage is maintained, but turning frequency is reduced to once every 2 hours. Isoprene splints can be used for the neck (Fig. 4), axilla (Fig. 5), elbows (Fig. 6), legs (Figs. 6 and 7) and hands (Fig. 1)." Exercising The exercise routine is increased to include sitting, walking and occupa-
aged to help overcome the patient's fear of using the burned limb. Active or assisted active movements of joints through as full a range of movement as possible and isometric exercises for large-muscle groups are done 10 times each, 3 times daily.2'5"0 Children too young to cooperate are subjected to gentle passive movements. Patients are
FIG. 4-Neck splint. Isoprene is softened in hot water (77C), dried with a towel and cooled slightly. It is applied directly to the neck, spreading from the centre outward to conform snugly but with the edges slightly flared. The cooling splint is held in place for 10 to 15 minutes, then removed for the attachment of Velcro straps with rapid rivets.
534 CMA JOURNAL/SEPTEMBER 18, 1976/VOL. 115
tional therapy. Positioning and activity are balanced to ensure maintenance of movement and avoid contractures. Hand care
Superficially burned hands are allowed free movement during the day but are splinted at night; deeply burned hands are splinted constantly except during exercise periods. Forced finger flexion is avoided to protect damage to extensor tendons from strain and rupture. Full mobilization begins when the dorsal surfaces of the fingers are healed. Grafting and early postgrafting stage This stage extends from the skin
grafting operation to about 14 days postoperatively. During the first 5 to 10 days the grafted area is immobilized in a dressing or restrained and left exposed to allow the graft to "take". Careful splinting is continued between exercise periods to prevent contractures. Splints can be worn directly or over light dressings on ulcerated areas but must be removed several times daily for cleaning of the ulcer and splint. Positioning FIG. 5-Axilla splint. After softening in hot water and drying, isoprene is applied directly to axilla, arm and chest, with arm abducted to 1100. A reinforcing isoprene strip (a) and aluminum rod (b) can be bonded to the splint, using carbon tetrachloride and rivets. Velcro strapping (c) is riveted on for fixation.
Neck: The neck is held in extension with a splinted dressing or a roll behind the neck and sandbags on either side of the head to prevent rotation. When the graft has taken (usually after about 2 weeks) a conforming splint (Fig. 4) is applied to avoid contracture.
Chest: The shoulders are held back; a small roll or pad between the shoulder blades helps to prevent contracture pulling the shoulders forward. Arms: The arms are held in extension by a plaster or isoprene splint in the dressing until the graft has taken, and then by an extension splint (Fig. 6). Legs: The legs are held in extension in the same way as the arms or by a rigid isoprene boot splint, which can be extended upward to immobilize the knee, as shown in Fig. 7. Exercising
A week to 10 days after grafting, gentle active and passive exercises are begun, often in the bath. Stretching exercises are stressed to avoid contracture. Late (stable graft) stage This stage begins 2 weeks after grafting and lasts until burn scars lose their red induration and become mature. Since the danger of contracture is maximal 6 to 12 weeks after grafting, restoration of full function is sought during this period. Continuous pressure and conforming splints help prevent and correct red
.1
OVERLAP
ANKLE HELD AT 900
ANTERIOR WIDTH OF FOOT .
DISTANCE FROM LOWER 1/3 OF CALF TO 1' ABOVE GREAT TOE
1/2 CIRCUMFERENCE OF LOWER 1/3 OF CALF
FIG. 6-Splints for dynamic extension of knees and elbows. Tensor bandages are wrapped around side-bars of splint at knee or elbow, pulling joint into extension, while isoprene pads at ends of bars hold proximal and distal portions of limb in position.
FIG. 7-Boot splint. Isoprene is softened in hot water, dried and applied to postenor surface of ankle. It is folded on itself at the sides of the ankle and when cooled is maintained in position by tensor bandaging or Velcro straps.
CMA JOURNAL/SEPTEMBER 18, 1976/VOL. 115 535
(immature) hypertrophic scars and contractures but have no effect on mature white or pigmented scars and scar contractures.'214 Constant pressure is best maintained on healed burn scars by the following measures: 1. Tensor bandages on limbs, applied over the burn scar and, if distal swelling occurs, distally to the digits. 2. Elastic pressure suits. These washable suits (Table I) are tailored to fit any area of the body. They are usually ordered for delivery just before the patient's discharge from hospital. 3. Rigid foam pressure face-mask (Table I). The mask is fabricated by the orthotist or physiotherapist, to be worn under an elastic pressure suit for the head. The suit applies pressure to the mask, which distributes it evenly over the face. 4. Conforming splints. Constant pressure is usually applied night and day for about 3 months and then only at night for another 3 months. If contractures begin to develop, splints must be worn for longer periods. Burn scars and grafts are lubricated twice daily with lanolin cream, petroleum jelly or bath oil, or a combination. Residual areas of ulceration can be covered with gauze dressings or simply with antimicrobial cream, and are cleansed two or three times daily. Areas of potential contracture are splinted with isoprene splints from about 2 weeks after grafting until the scar has matured. Splints are usually worn continuously (except for occupational therapy, physiotherapy and washing) for 3 months and then only at night for a further 3 months; they are checked and remodelled or remade as needed to conform to the changing skin surfaces as the scars mature. Positioning Face: A rigid foam face-mask is worn under an elastic pressure suit for the head to maintain facial shape and avoid contractures. Neck: Neutral rotation and moderate extension are held with a snugly fitting, neck-conforming splint (Fig. 4) designed to elevate the chin and reduce the neck circumference. If ulceration develops under the chin or on the upper part of the chest, frequent splint removal and cleansing are instituted or the patient temporarily wears an elastic pressure suit for the neck. Splinting is particularly important for the neck: without it severe contractures may develop within a few days. Axillae: The arms are held in moderate abduction with slight flexion. Contracture of mild to moderate axillary scars can be prevented by the
application of foam pads kept in place with a figure-of-eight tensor bandage. If the axillae are severely burned a conforming splint is necessary (Fig. 5). Elbows: The elbows are held in extension by a dynamic splint (Fig. 6), except during therapy and eating, for the first 2 weeks, and then at night and as required to prevent contracture. Hands: The metacarpophalangeal joints are kept in flexion and the interphalangeal joints in extension. A conforming hand splint (Fig. 1) is worn continuously except during therapy for the first 2 weeks, and then only when the hands are not being actively used. The hand is tensor-bandaged into the splint. Specially designed splints are used to prevent specific deformities (for example, with plastic tubing held tightly in the web spaces by elastic bands to prevent burn-scar syndactyly) and dynamic splints are used to increase finger or wrist extension while allowing use of the hand. Hips: The hips are kept in extension, with the patient lying prone, for half an hour three times a day. Sandbags can be placed on the knees while the patient is supine. Knees: The knees are kept in extension (as for the elbows) and splinted (Figs. 6 and 7). Feet: Ankles and toes are kept in neutral position in an isoprene boot with tensor bandaging over padding on the dorsal toe surfaces. Exercising Exercises through a full range of movement are continued daily to ensure that no contractures develop. Walking with tensor bandages applied to the legs is begun 2 weeks after legburn grafting. Sitting for long periods is avoided because it encourages hip and knee flexion contractures, and a wheelchair is not used. A program of gross motor activity is instituted, using large balls, skate boards and bicycles, to encourage normal whole-body movements; swimming is especially helpful. Independence in dressing, feeding and personal hygiene is encouraged. Instruction of parents in home care
tive such as methdilazine hydrochloride, cyproheptadine hydrochloride or trimeprazine tartrate is prescribed. Excellent musculoskeletal management in hospital may be to no avail if problems encountered by the patient after his return home lead to poor positioning and reduced movement. We find it imperative to maintain close contact with the parents and patient and other health professionals responsible for care; burn scars are constantly evolving, particularly in growing children, and splints and pressure appliances must be evaluated frequently and adopted whenever required. A firm approach is often necessary to ensure that splints are worn optimally. Parents must be counselled against overprotecting the patient and instructed that it is better to lose a small piece of skin or get a blister while playing than not to engage in sports at all. The help of an interested social worker is extremely beneficial in coordinating the burned child's return to his community. We thank the medical publications department for help with the manuscript, and the visual education department, The Hospital for Sick Children. References 1. DOBBS ER, CURRERI PW: Bums: analysis of results of physical therapy in 681 patients. J Trauma 12: 242, 1972 2. EVANS EB, LARSON
DL, ABSTON S, et al:
Prevention and correction of deformity after severe burns. Surg Clin North Am 50: 1361, 1970
3. GOLDBERG RT: Rehabilitation of the burn patient. Rehabil Lit 35: 73, 1974 4. KOEPKE GH: The role of physical medicine in the treatment of burns. Sung Clin North Am 50: 1385, 1970 5. EVANS EB: Orthopedic measures in the treatment of severe burns. J Bone Joint Surg [Am] 48A: 643, 1966 6. EVANS EB, LARSON DL, YATES 5: Preservation and restoration of joint function in patients with severe burns. JAMA 204: 843, 1968 7. LARSON DL, WOFFORD BH, EVANS EB, et al: Repair of the boutonniere deformity of the burned hand. I Trauma 10: 481, 1970 8. TAN IGAWA MC, O'DONNELL OK, GRAHAM PL: The burned hand: a physical therapy
protocol. Phys Ther 54: 953, 1974
9. HEIMBLrRGER RA, MARTEN E, LARSON DL, et al: Burned feet in children, acute and reconstructive care. Am J 5mg 125: 575, 1973
10. JAEGER DL: Maintenance of function of the burn patient. Phys Ther 52: 627, 1972
Before the child goes home he and his parents are instructed in (a) rangeof-movement exercises, (b) splint application and wearing times, (c) dressings, (d) increasing independence in routine activities, (e) sports participation, (f) schooling (as soon as possible, in a routine as normal as possible) and (g) management of itchy, dry skin by cool baths and the application of bath oil. The need for light, cool clothing is stressed and an antihistamine seda-
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11. WILLIs B: A follow-up. The use of Orthoplast isoprene splints in the treatment of the acutely burned child. An, I Occup Ther 24: 187, 1970 12. FUJIMoRI R, HIRAMOTO M, OFuJI 5: Sponge fixation method for treatment of early scars.
Plast Reconstr Surg 42: 322, 1968
13. LARSON DL, ABsToN 5, EVANS EB, et al:
Techniques for decreasing scar formation and contractures in the burned patient. I Trauma 11: 807, 1971
14. WILLIs B: The use of Orthoplast isoprene splints in the treatment of the acutely burned child: preliminary report. Am I Occup Ther 23: 57, 1969
