Burn rehabilitation and research: proceedings of a consensus summit

Intensive swallowing and orofacial contracture rehabilitation after severe burn: A pilot study and literature review

BACKGROUND

Dysphagia following severe burns can be significant and protracted, yet there is little evidence describing the rehabilitation principles, process or outcomes.

PURPOSE

Outline current evidence and detail the clinical outcomes of two cases who underwent a multifaceted intensive treatment programme aimed at rehabilitating dysphagia by strengthening swallow function and minimising orofacial contractures after severe head and neck burns.

METHODS

Two men (54 and 18 years) with full-thickness head and neck burns and inhalation injury underwent intensive orofacial scar management and dysphagia rehabilitation. Therapy was prescribed, consisting of scar stretching, splinting and pharyngeal swallow tasks. Horizontal and vertical range of movement (HROM; VROM), physiological swallow features, functional swallowing outcomes and related distress, were collected at baseline and routinely until dysphagia resolution and scar stabilisation.

RESULTS

At presentation, both cases demonstrated severely reduced HROM and VROM, profound dysphagia and moderate dysphagia related distress. Therapy adherence was high. Resolution of dysphagia to full oral diet, nil physiological swallowing impairment, and nil dysphagia related distress was achieved by 222 and 77 days post injury respectively. VROM and HROM achieved normal range by 237 and 204 days.

CONCLUSION

Active rehabilitation achieved full functional outcomes for swallowing and orofacial range of movement. A protracted duration of therapy can be anticipated in this complex population.

Orofacial Contracture Management: Current Patterns of Clinical Practice in Australian and New Zealand Adult Burn Units

Burn injury to the face can lead to scarring and contractures that may impair oral competence for articulation, feeding, airway intubation access, oral/dental hygiene, aesthetics, and facial expression. Although a range of therapy interventions has been discussed for preventing contracture formation, there is minimal information on current practice patterns. This research examined patterns of clinical practice for orofacial burns management during a 4-year period to determine the nature and extent of clinical consistency in current care. Allied health clinicians involved in orofacial contracture management in Australia and New Zealand were surveyed at two time points (2010 and 2014). Twenty and 23 clinicians, respectively, across a range of allied health professions completed the surveys. Both surveys revealed multiple allied health disciplines, predominantly occupational therapy, speech language pathology, and physiotherapy, were involved orofacial burn management. A high degree of variation was observed across clinical practices in the 2010 survey. In the 2014 survey, although, greater consistency in practice patterns was observed with more clinicians commencing intervention earlier, with greater treatment intensity observed and more treatment modalities being used. Furthermore, in 2014, there was an increased use of assessment tools and clinical indicators to guide patient treatment. Agreement regarding clinical practice pathways for orofacial contracture rehabilitation is still emerging, and treatment continues to be predominantly guided by clinical experience. There is an urgent need for treatment efficacy research utilizing validated outcome measure tools to inform clinical consensus and practice guidelines.

Sedation and analgesia for critically ill pediatric burn patients: the current state of practice

The objective of this study was to assess current practice patterns and attitudes toward pediatric sedation and analgesia in United States (US) burn centers for critically ill patients. Survey-based questionnaire was sent to 119 Directors at US burn centers that care for pediatric patients. Forty-one surveys (34%) were analyzed. 48.8% of responding centers mandate pediatric consultation for pediatric burn patients based on factors such as age and burn size. The most common sedation and analgesic agents used were midazolam, fentanyl, morphine, ketamine, and diphenhydramine. Written sedation policies exist at 63.4% of centers. 90.2% of centers employ scoring systems to guide agent titration. 60.9% of respondents practice sedation holidays "always" or "usually." 90.2% of centers perceive the medications they routinely use are "always" or "often" efficacious in pediatric sedation and analgesia. 53.7% of respondents reported the presence of withdrawal signs and symptoms in their patient population. The lack of consensus guidelines for sedation and analgesia delivery to pediatric intensive care unit patients results in practice variation. The majority of centers perceive their sedation and analgesia strategies to be efficacious despite the heavy reliance on propofol and midazolam, both of which have questionable safety profiles in critically ill children.

Acute burns of the hands - physiotherapy perspective

BACKGROUND

Acute burns of the hands are complex and may impact on various aspects of a person's life. Physiotherapy rehabilitation and restoration of hand function is critical for the patient's independence and re-integration into society.

PURPOSE

This study aimed to explore the perceptions and experiences of physiotherapists in the management of patients with their hand burn injuries.

METHOD

Five focus groups consisting of physiotherapists and physiotherapy assistants working with burn injured patients from each of the five selected public hospitals in KwaZulu-Natal were recruited. An explorative qualitative approach was adopted.

RESULTS

Physiotherapists emphasised that the acute management of the hand was trivialised due to a primary focus on the survival of the burn sufferer. Therapists identified several factors that determined the patients' level of participation and motivation in therapy one of which was the procedural pain experienced. The role of the therapists' within the rehabilitation framework was found to be critical to their recovery however there appeared to be a breakdown in the collaboration and communication among health care professionals to the detriment of effective intervention.

CONCLUSION

A multidisciplinary team approach is the foundation in the management of acute burn injuries and during the trajectory of the trauma care continuum.

The speech-language pathologist's role in multidisciplinary burn care: An international perspective

PURPOSE

To explore international practices of speech-language pathology (SLP) within burn care in order to provide direction for education, training and clinical practice of the burns multidisciplinary team (MDT).

METHOD(S)

A 17-item online survey was designed by two SLPs experienced in burn care with a range of dichotomous, multiple choice and open-ended response questions investigating the availability and scope of practice for SLPs associated with burn units. The survey was distributed via professional burn association gatekeepers. All quantitative data gathered were analysed using descriptive statistics and qualitative data were analysed using content analysis.

RESULT(S)

A total of 240 health professionals, from 6 different continents (37 countries) participated within the study. All continents reported access to SLP services. Referral criteria for SLP were largely uniform across continents. The most dominant area of SLP practice was assessment and management of dysphagia, which was conducted in concert with other members of the MDT.

CONCLUSION

SLP has an international presence within burn care that is currently still emerging.

Patient adherence to burn care: A systematic review of the literature

OBJECTIVE

Few studies have been conducted on treatment adherence to burn care. Given the prevalence of burn injuries across the lifespan and the impact of proper burn care on associated morbidity, it is important to understand factors associated with regimen non-adherence in this population. The purpose of this paper is to summarize and critique all published literature on patient adherence to burn care.

METHOD

With no restriction on publication date, 13 relevant articles met the following inclusion criteria: (a) utilized a sample of patients who sustained a burn injury or their medical staff; (b) focused on treatment or healthcare adherence of the patient (e.g., adherence to pressure garment therapy, physical therapy, occupational therapy, diet, dressing changes, or sunscreen use); and (c) publication written or translated into English.

RESULTS

Most studies (70%) used a correlational design, while only four studies used an experimental design (either longitudinal or single subject) to assess adherence to burn care treatment. Current research suggests that burn treatment characteristics, knowledge, and beliefs are associated with adherence to burn care regimens.

CONCLUSIONS

Given that adherence may vary as a function of different factors, future research should assess pediatric burn patients as a separate population, as well as investigate adherence to multiple aspects of the burn care regimen. To enhance adherence to burn care, healthcare providers should educate their patients on various treatment components and tailor these components to meet patients' goals and needs, as feasible.

Clinical outcomes from a foam wedge splinting program for axillary contracture prevention in the intensive care unit

Preventing scar contracture after burn injury is a critical goal during recovery. Although the need for intervention is well-understood, data on specific techniques are limited. The study's objective is to provide data for the use of a foam abduction wedge in terms of safety, effectiveness, and patient and caregiver satisfaction through a prospective, single-arm trial. All patients presenting with a burn injury that required grafting in the axillary region and placed them at risk for shoulder joint contracture were offered inclusion. Patient outcomes were recorded for the duration of their burn intensive care unit admission. Ten subjects completed the protocol with a mean duration of wedge use of 41.5 ± 32.5 days. At discharge, the mean shoulder abduction was 132° ± 38° on the left and 118° ± 22° on the right. The mean shoulder flexion was 132° ± 31° on the left and 123° ± 29° on the right. As much as 90% of the subjects had greater than 90° of shoulder abduction and flexion at discharge. There were no observations of worsening burn injury wounds, graft failure, or new pressure-related wounds. One patient was found to have an upper-extremity peripheral nerve injury that was not clearly associated with the splint. Patient and nursing surveys indicated areas of satisfaction as well as areas for potential improvement. This study illustrates the anticipated clinical outcomes and care issues associated with the use of a specific contracture prevention method used in the burn intensive care unit setting as well as identifying areas for future research.

A polarized multispectral imaging system for quantitative assessment of hypertrophic scars

Hypertrophic scars (HTS) are a pathologic reaction of the skin and soft tissue to burn or other traumatic injury. Scar tissue can cause patients serious functional and cosmetic issues. Scar management strategies, specifically scar assessment techniques, are vital to improve clinical outcome. To date, no entirely objective method for scar assessment has been embraced by the medical community. In this study, we introduce for the first time, a novel polarized multispectral imaging system combining out-of-plane Stokes polarimetry and Spatial Frequency Domain Imaging (SFDI). This imaging system enables us to assess the pathophysiology (hemoglobin, blood oxygenation, water, and melanin) and structural features (cellularity and roughness) of HTS. To apply the proposed technique in an in vivo experiment, dermal wounds were created in a porcine model and allowed to form into scars. The developed scars were then measured at various time points using the imaging system. Results showed a good agreement with clinical Vancouver Scar Scale assessment and histological examinations.

Patterns of recovery over 12 months following a burn injury in Australia

OBJECTIVE

To describe patients' generic health status and health-related quality of life (HRQoL) 12-months following admission to a state-wide burns service.

METHODS

A total of 114 injured adults with >10% total body surface area burned (TBSA) or burns less than 10% TBSA to smaller anatomical areas such as the hands and feet participated in this study. Retrospective assessment of pre-burn injury status and prospective assessment of generic health and HRQoL were followed up at 3, 6 and 12-months after injury using the 36-item Short Form Health Survey (SF-36 v.2) and Burns Specific Health Scale-Brief (BSHS-B). The SF-36 v.2 was administered retrospectively during the initial hospital stay to assess pre-injury HRQoL. Changes in instruments scores were assessed using multilevel mixed effects regression models. Mean scores were compared over time and between severity groups as defined by <10%, 10-30% and >30% TBSA.

RESULTS

For the overall sample, the SF-36 v.2 physical component scale (PCS) score between 3 and 12-months post-burn injury were significantly lower than pre-injury scores (p<0.01), with no significant change over time for the mental component scale (MCS) (p=0.36). Significant %TBSA-burden by time interactions highlighted changes from pre-burn injury in overall PCS (p=0.02), physical functioning (p<0.001) and role-physical (p=0.03), with subscales worse for the TBSA >30% group. With respect to the BSHS-B, significant improvement from 3 to 12-months post-burn injury was seen for the entire sample in simple abilities (p<0.001), hand function (p=0.001), work (p=0.01), and treatment regime (p=0.004) subscales. The TBSA >30% group showed a greater rate of improvement in simple abilities (p=0.01) and hand function (p=0.005) between 3 and 12 months post-burn injury.

CONCLUSIONS

Whilst certain HRQoL measures improve over the 12-months, in most cases they do not reach pre-morbid levels. Patients face ongoing challenges regarding their physical and psychosocial recovery 12-months post-burn injury with respect to generic health and burn-specific health. These challenges vary at different time periods over the 12-month post-burn period, and may provide windows of opportunity in which to address ongoing issues.

Treating burn-associated joint contracture: results of an inpatient rehabilitation stretching protocol

The prevention and treatment of scar contracture is critical after significant burn injuries to avoid functional impairment. However, descriptions of specific contracture treatment interventions and outcomes are limited. Our objective is to provide detailed information and range of motion outcomes regarding the use of an intensive stretching protocol for burn-associated contracture. As part of a quality improvement measure, all patients admitted to inpatient rehabilitation with burn injury were treated with at least 1 hour of daily stretching by experienced therapists and were tracked with standardized range of motion measurements. Eighty-eight joint contractures were treated across nine patients for up to 4 weeks. The average weekly improvement in range of motion was 8.2 degrees (95% confidence interval [CI], 6.5-9.9). The largest gains were seen in the first week of treatment with an average improvement of 11.2 degrees (95% CI, 8.7-13.6). Eighteen digit contractures were treated across four patients. The average weekly improvement in flexion was 7.2 mm (95% CI, 5.2-9.1) again with larger gains in the first week of treatment-12.8 mm (95% CI, 10.3-15.4). Thumb opposition improved across five patients in the first week with an average improvement of 1.4 on the opposition scale (95% CI, 0.4-2.5). Intensive stretching by experienced therapists yielded significant improvements in joint range of motion for patients with burn-associated joint contracture. Defining specific burn contracture interventions remains a key goal in advancing burn rehabilitation in the future.

Assessment of health status of adolescent burn victims undergoing rehabilitation: a cross-sectional field study

Teenagers may experience physiological and psychological changes when they suffer from a severe burn. The aim of this study was to assess the state of health of teenagers who were undergoing a rehabilitation process following a severe burn. A cross-sectional field study was carried out with 63 teenagers and young adults who had suffered burns. The tests applied were social, demographic, and clinical instruments. The specific tests included the Burn Specific Health Scale-Revised, Beck Depression Inventory, Rosenberg's Self-Esteem Scale, and Functional Independence Measurement. The results were analyzed by using descriptive statistics, multivariate analysis of variance, variance analysis, and Cronbach's reliability analysis. The social and demographic analysis of the population has shown a prevalence of female (60.3%), single subjects (93.7%), and ages between 12 and 20 years (mean age of 15.95 years). The mean total body surface area burn was 23.84%, with accidents as the main causative factor (92.10%). More than half (52.4%) reported functional and aesthetic effects after the burn, with 81% concerned about the visible scar. Cronbach's reliability analysis has shown statistically confident results for all the instruments as applied. The multivariate analysis showed a correlation between the work domain and marital status, whereas there was no evidence to show a correlation between sex, age, physical or aesthetic sequelae or visibility of burns, and depression, self-esteem, functional independence, or current state of health. The results obtained prove the reliability of the instruments applied, making it possible to assess the state of teenagers and young adults health during the rehabilitation process.

Health-related quality of life of hospitalized patients with burns-comparison with general population and a 2-year follow-up

OBJECTIVE

Health-related quality of life (HRQoL) has gained increasing interest as an important indicator of adaptation after a burn injury. Our objective was to compare HRQoL of medium severity hospitalized burn victims with no need for intensive care treatment with that of the general population.

METHODS

The 15D HRQoL questionnaire at discharge, and 6, 12 and 24 months thereafter.

RESULTS

44 patients filled in the baseline questionnaire between June 2007 and December 2009. At discharge the mean (SD) HRQoL score (on a scale of 0-1) of the patients was worse in comparison with that of the general population (0.839 (0.125) vs. 0.936 (0.071)), p<0.001. The most striking differences (p<0.001) were seen on the dimensions of sleeping, usual activities, discomfort and symptoms, and sexual activity. At the 2-year follow-up the mean HRQoL score had increased from 0.835 (0.121) to 0.856 (0.149), but the difference was not statistically significant. Of the dimensions, moving and usual activities improved statistically significantly.

CONCLUSIONS

HRQoL of patients hospitalized for treatment of burns is, at discharge, compromised compared with that of the general population. During follow-up HRQoL showed slight improvement but remained at a clearly lower level.

Assessment of pruritus characteristics and impact on burn survivors

The goal of this cross-sectional study was to characterize and describe persistent postburn pruritus. Cause and treatment of postburn itch is elusive. It has been suggested that burn survivors with persistent pruritus should be divided into acute itch (≤6 months postinjury) and chronic itch (>6 months postinjury) because the cause of itch may be different. Cross-sectional data of itch characteristics reported here are from the baseline data of a prospective, randomized, double-blind, controlled pilot study of 23 subjects with frequent and bothersome postburn pruritus. Subjects self-completed validated scales for variables of itch sensation, affect of itch, and severity. Variables of quality of life, frequency, pain and itch intensity, skin condition, scar, and medication were also recorded. Itch frequency revealed that 87% of subjects experienced itching daily, 96% experienced three or more episodes a day, and 52% had episode durations lasting 5 to 30 minutes per incidence. Itch was reported as unbearable by 94% of subjects with chronic itch and by 86% of subjects with acute itch, whereas bothersome was 88 and 100%, respectively. Itch sensation dimension of stinging was 74% in both acute and chronic itch subjects. Crawling and burning sensations were often severe. Potential itch triggers and relief activities were identified. Differences in sensory and affective itch components were detected between acute and chronic itch subjects. Combinations of itch mechanisms probably contribute to the development of and changes in pruritus. Characterizing the sensation and affective itch dimensions in conjunction with inflammation, burn injury, recovery, scar maturation, medication, and psychological status should better elucidate postburn itch.

Practice guidelines for early ambulation of burn survivors after lower extremity grafts

The objective of this review was to systematically evaluate the available clinical evidence for early ambulation of burn survivors after lower extremity skin grafting procedures so that practice guidelines could be proposed. It provides evidence-based recommendations, specifically for the rehabilitation interventions required for early ambulation of burn survivors. These guidelines are designed to assist all healthcare providers who are responsible for initiating and supporting the ambulation and rehabilitation of burn survivors after lower extremity grafting. Summary recommendations were made after the literature, retrieved by systematic review, was critically appraised and the level of evidence determined according to Oxford Centre for Evidence-Based Medicine criteria. A formal consensus exercise was performed to address some of the identified gaps in the literature which were believed to be critical building blocks of clinical practice.

Burn survivors' perceptions of rehabilitation

BACKGROUND

The perspectives of burn survivors offer a powerful tool in assessing the efficacy of burn therapy interventions and methods. Despite this potential wealth of data, comprehensive analysis of burn survivor feedback remains largely uninvestigated and underdocumented. The aim of this study was to evaluate specific burn therapy interventions based on the opinions of a sample of the burn community.

METHODS

The survey was distributed to a convenience sample drawn from burn survivors attending the Phoenix Society's 21st Annual World Burn Congress in New York City, New York. Items of inquiry focused on therapeutic intervention and reintegration. The 164 surveys (a 44% response rate) returned included burn survivors from a variety of demographic segments and with burn injuries of disparate size, location, and severity. Interventions of interest included splinting and positioning, pressure garments, therapeutic exercise, group therapy, and nontraditional therapy. Respondents also rated the contribution of acute burn rehabilitation toward reintegration into familial, societal, and professional roles.

RESULTS

The vast majority of respondents felt that the rehabilitative interventions they experienced positively affected their long-term physical and psychosocial outcomes. In the areas of improving movement and scarring and expediting reintegration and usefulness, the majority of applicable interventions generated "strongly agree" or "agree" as the most popular responses.

CONCLUSIONS

These findings support the efficacy of many practices employed by burn rehabilitation specialists and offer a glimpse into the inherent benefits found in assessment of burn survivors' perspectives.

Clinical competencies for burn rehabilitation therapists

Nationally agreed-upon standards for competence are needed for burn physical and occupational rehabilitation therapists (BRTs) to define what constitutes safe and competent burn rehabilitation practice. Currently, consensus regarding the knowledge and skill components needed for the training and evaluation of BRT job performance is lacking. The Rehabilitation Committee of the American Burn Association used a staged, multimethod approach and input from more than 25 experts in the burn rehabilitation community to develop competency standards for BRTs. The result was the "Burn Rehabilitation Therapist Competency Tool" (BRTCT) that defines competency domains required of BRTs to provide physical and occupational therapy to patients with burn injury during their initial acute hospitalization and rehabilitation. This article describes the staged development and validation of the BRTCT. The component parts of the tool itself are presented, and the recommendations for assessment of competence are discussed. The BRTCT provides a common framework and language for expectations of performance in burn rehabilitation. Development of the BRTCT is a critical step in the ongoing process of promoting professional development and consistent practice standards in burn rehabilitation.

A review on static splinting therapy to prevent burn scar contracture: do clinical and experimental data warrant its clinical application?

BACKGROUND

Static splinting therapy is widely considered an essential part in burn rehabilitation to prevent scar contractures in the early phase of wound healing. However, scar contractures are still a common complication. In this article we review the information concerning the incidence of scar contracture, the effectiveness of static splinting therapy in preventing scar contractures, and specifically focus on the - possible - working mechanism of static-splinting, i.e. mechanical load, at the cellular and molecular level of the healing burn wound.

METHOD

A literature search was done including Pubmed, Cochrane library, CINAHL and PEDRO.

RESULTS

Incidence of scar contracture in patients with burns varied from 5% to 40%. No strong evidence for the effectiveness of static splinting therapy in preventing scar contracture was found, whereas in vitro and animal studies demonstrated that mechanical tension will stimulate the myofibroblast activity, resulting in the synthesis of new extracellular matrix and the maintenance of their contractile activity.

CONCLUSION

The effect of mechanical tension on the wound healing process suggests that static splinting therapy may counteract its own purpose. This review stresses the need for randomised controlled clinical trials to establish if static splinting to prevent contractures is a well-considered intervention or just wishful thinking.

Rehabilitation of the burn patient

Rehabilitation is an essential and integral part of burn treatment. It is not something which takes place following healing of skin grafts or discharge from hospital; instead it is a process that starts from day one of admission and continues for months and sometimes years after the initial event. Burns rehabilitation is not something which is completed by one or two individuals but should be a team approach, incorporating the patient and when appropriate, their family. The term ‘Burns Rehabilitation’ incorporates the physical, psychological and social aspects of care and it is common for burn patients to experience difficulties in one or all of these areas following a burn injury. Burns can leave a patient with severely debilitating and deforming contractures, which can lead to significant disability when left untreated. The aims of burn rehabilitation are to minimise the adverse effects caused by the injury in terms of maintaining range of movement, minimising contracture development and impact of scarring, maximising functional ability, maximising psychological wellbeing, maximising social integration

Local and systemic treatments for acute edema after burn injury: a systematic review of the literature

Burn injury is a complex trauma that results in local and generalized edema. Edema fluid limits the exchange of vital nutrients in healing the burn wound and will compromise vulnerable tissues. Although the importance of edema control in tissue salvage is recognized, treatments targeted at edema control have not been critically reviewed. Thus, the objective was to assess the evidence for the effectiveness of local and systemic treatments for edema management immediately after burn injury. Searches for randomized controlled trials were conducted of online databases, research and thesis registers, and grey literature repositories. Handsearches included journals, bibliographies, and proceedings. Authors were contacted to clarify and submit extra study details. Eight studies were included. Management of acute major burn resuscitation including colloid increases lung edema (mean difference [MD], 0.04 ml/ml alv vol; 95% confidence interval [CI], 0.03-0.04; P < .00001) and mortality (risk ratio, 3.67; 95% CI, 1.16-11.58; P = .03). Continuous administration of vitamin C in acute burn resuscitation reduces local wound edema (MD, -3.50 ml/g; 95% CI, -4.63 to -2.37; P < .00001) and systemic fluid retention (MD, -8.60 kg; 95% CI, -13.47 to -3.73; P = .0005). Local acute hand burn edema is reduced (MD, -29.00 ml; 95% CI, -53.14 to -4.86; P = .02), and active hand motion increased (MD, 10.00°; 95% CI, 4.58-15.42; P = .0003), using electrical stimulation with usual physiotherapy. Each review outcome was based on a small single-facility study. Thus, future research in intervention for acute burn edema must focus on multicentre trials and validation of outcome measures in the burn population.

Select practices in management and rehabilitation of burns: a survey report

The purpose of this study is to document the organization and current practices in physical rehabilitation across burn centers. An online survey developed for the specific purposes of this study sought information regarding a) logistics of the burn center; b) inpatient and outpatient treatment of patients with burn injury; and c) specific protocols in the treatment of a few complications secondary to burn injuries. Of the 159 responses received, 115 were received from the United States, 20 from Australia, 16 from Canada, and 7 from New Zealand. The overall sample included responses from 76 physical therapists (PTs) and 78 occupational therapists. Seventy-three of those surveyed considered themselves primarily a burn therapist. Nurses (86%) were reported as primarily responsible for wound care of inpatients, followed by wound care technicians (24%). Ninety-seven percent of the therapists reported following their own treatment plans. The trunk and areas of head and neck were treated by both PTs and occupational therapists, whereas the lower extremities continue to be treated predominantly by PTs. Some common practices regarding treatment of a few complications secondary to burn injuries such as splinting to prevent contractures, treatment of exposed or ruptured extensor tendons, exposed Achilles tendons, heterotopic ossification, postoperative ambulation, conditioning, scar massage, and use of compression garments are described. Opportunities exist for 1) developing a common document for practice guidelines in physical rehabilitation of burns; and 2) conducting collaborative studies to evaluate treatment interventions and outcomes.

An overview of war-related thermal injuries

Thermal injuries have always been a source of morbidity and mortality in times of war. Historically, they constitute 5% to 20% of all injuries and approximately 4% mortality. Although burn patients constitute a small number of casualties, they consume a disproportionate amount of resources and require specialized care. The current conflicts in the Middle East report similar numbers for thermal injuries despite improvement in predeployment education to reduce noncombat-related burns, flame retardant military clothing, and decline of war patterns usually associated with increased thermal injuries. However, the increased use of improvised explosive devices and vehicle-borne improvised explosive devices presents a new source of potential thermal injury. Indeed, the burden of explosion-related burns has increased as has its associated Injury Severity Score. As has been the case in previous conflicts, most burns are hand and head burns. Although usually not life threatening, burns to hands and face lead to significant physical and psychologic morbidities. In this paper, we will review the currently available literature on war-related thermal injuries in Operation Iraqi and Operation Enduring Freedom. We will describe the epidemiology of burn injuries, prewar preparation to prevent and treat thermal injuries, and the assessment, triage, and final treatment of burn patients. In addition, we will discuss the associated physical and psychologic morbidities and, finally, the role of plastic surgeon in burn rehabilitation and reconstruction.

Rehabilitation of the burned hand

Successful outcomes following hand burn injury require an understanding of the rehabilitation needs of the patient. Rehabilitation of hand burns begins on admission, and each patient requires a specific plan for range of motion and/or immobilization, functional activities, and modalities. The rehabilitation care plan typically evolves during the acute care period and during the months following injury.