Outcomes of Early and Intensive Use of a Palm and Digit Extension Orthosis in Young Children After Burn Injury

Scar outcomes for conservatively managed children post burn injury: A retrospective study

Hypertrophic scarring is a significant complication post burn injury, especially for delayed healing after 3 weeks. Burn injuries healing prior to 3 weeks also have the potential to develop hypertrophic scarring, even when prescribed prophylactic conservative scar interventions. A retrospective chart audit reviewed 326 burn patients treated at a paediatric tertiary hospital from 2014 to 2019 who sustained a partial thickness burn, healed >14 days and did not receive skin grafting. A scar was deemed hypertrophic if >1 mm in height. Early hypertrophic scar prevalence was defined as 3-6 months post burn, while persistent hypertrophic scarring was defined as 12-18 months post burn. Median days to wound closure was 18. The prevalence of early and persistent hypertrophic scarring was 56.1% and 16.3%, respectively. Seventeen (5.2%) children underwent medical interventions for scar modulation. Early signs of hypertrophic scarring were seen in just over half the patients presenting to burn therapy and despite scar intervention, persistent hypertrophic scarring was seen in 16.3%. At both time points, just over half of the children presenting healed between 14 and 21 days. Therefore, children healing prior to 21 days have potential to develop hypertrophic scarring.

Cutaneous functional units prediction in outcomes of early and intensive splinting following palmar burn injury in young children: a prospective study

BACKGROUND

Palmar burn injuries are common in young children and can result in contracture.

METHODS

A prospective longitudinal study describes outcomes of palm and digit extension splint use following burn in 75 children (83 hands) aged < 5 years and determines whether specific cutaneous functional units (CFUs) are associated with early signs of contracture (ESC). Outcomes were assessed up to 9-18 months following burn. Routine clinical data was collected at therapy reviews.

RESULTS

Children were splinted > 12 h/day for a mean of 158 days following burn. The mean time to splint cessation was 264 days following burn. Fourteen hands developed ESC (17%): 12 hands had full ROM restored following conservative management, 2 hands (3%) progressed to contracture. Hands that developed ESC had greater healing time (p = 0.002), greater number of CFUs affected (p < 0.001), and greater number of immediate first webspace and extended first webspace CFUs affected (p = 0.002, p < 0.001 respectively). ESC risk increases for each day to heal (odds ratio [OR] 1.1, 95% CI 1.0-1.2) and each CFU in extended first webspace (OR 2.8, 95% CI 1.5-5.0).

CONCLUSION

Early and intensive splinting following palmar burn results in excellent ROM. Burns involving more CFUs or the first webspace are associated with ESC.

Parent perspective of an intensive splinting intervention following palmar burn injury in young children

BACKGROUND

Parents may experience challenges implementing their child's therapeutic treatment following burn.

METHODS

A mixed methods study was conducted to explore the parent experience of intensive splinting following palmar burns in young children (median age 16 months [IQR 14]). Thirteen parents were interviewed after cessation of their child's splinting (mean 12 months [SD 2] following burn). Parent interviews were semi-structured with open-ended questions and conducted one-to-one. Inductive thematic analysis was completed by two researchers with consensus achieved through discussion and agreement from third researcher. Themes were triangulated with quantitative data, including range of motion (ROM), scar, developmental and quality of life outcomes.

RESULTS

Children used the splint intensively (>12-24 h/day) for median 179 days (IQR 74) with all splinting ceased by median 275 days (IQR 105). All children had full ROM at scar maturation. Thematic analysis revealed two main themes: parents perceive the impact of splinting to be greater on them than their child and parents perceive outcomes to be more important than burden. Parents described the importance of routine and therapeutic relationships in ongoing engagement with intervention.

CONCLUSION

Parents consider intensive splinting to impact them more than their child with burden of care manageable considering overall outcomes.

Rehabilitation Management of the Burned Hand

Burns to the hands constitute a small total surface area burn, but can result in significant functional challenges and disability. The complexity of multiple anatomical structures and intricate interplay of bones, muscles, and connective tissues requires specialized knowledge of how burns of the hand can affect function and independence. This article will provide an evidence-based overview of rehabilitation of the burned hand across the burn care continuum including a focus on evaluation, pain management, treatment interventions, and outcome assessment. Additionally, various deficits that can put the hand at significant risk for loss of function will be discussed. Finally, the authors will address the special considerations and treatment caveats of addressing the pediatric hand burn.

Reliability, Validity, and Predictive Validity of Cutaneous Functional Units Predicted to Scar Following Palmar Burn Injury in Young Children

Identification of children at risk of palmar burn scar is important for early initiation of scar management. This study determined the interrater reliability of face-to-face and photographic assessments of 29 palmar cutaneous functional units (CFUs) predicted to scar following palmar burn. The validity of photographic compared to face-to-face assessment, and the predictive validity of both assessment types to identify scarring at 3 to 6 months following burn, was also established. Thirty-nine children (40 hands) post burn injury were assessed face-to-face in the clinical setting, following healing of their palmar burn, by three burn therapists. Photographs of the children's hands at initial assessment were assessed by the same therapists a minimum of 6 months later. To determine which CFUs scarred, children were reassessed face-to-face in the clinical setting 3 to 6 months following their burn. For analysis, 29 CFUs were merged into eight separate groups to determine the number of CFUs predicted to scar per CFU group for face-to-face and photographic assessments. The range of agreement for individual CFUs within CFU groups was also calculated for both assessment types. Excellent interrater reliability was established for face-to-face assessment in all eight CFU groups (ICC2,1 0.83-0.96). Photographic assessment demonstrated good to excellent interrater reliability in six CFU groups (ICC2,1 0.69-0.90) and validity in seven CFU groups (ICC2,1 0.66-0.87). Good to excellent predictive validity was established for both assessment types in seven CFU groups (face-to-face ICC2,1 0.60-0.95, photographic ICC2,1 0.69-0.89). Experienced therapists can reliably assess CFUs face-to-face or via photographs and predict future scar development.

Reliability of a novel technique to assess palmar contracture in young children with unilateral hand injuries

BACKGROUND

Palmar contracture in young children can have significant developmental consequences. Despite this, objective techniques to measure palmar range of movement and quantify contracture in young children are limited.

PURPOSE

The purpose of this study was to determine the reliability of hand span and hand length measures in young children and to establish whether there is any association with age, sex and presence of a palmar burn injury in the reliability of these measures. The study also sought to determine the normative difference and establish a cut off value for the between-hand difference to identify loss of movement in 1 hand.

STUDY DESIGN

Cross sectional METHODS: Forty-four children aged 0 to <5 years were recruited. Twenty-two children had a unilateral palmar burn injury and 22 did not have a palmar burn injury. Each child's hand span and hand length were measured 3 times. This was performed twice by the first assessor and once by the second assessor. Intraclass correlation coefficients were calculated to determine the intra-rater and inter-rater reliability. The largest of the 3 values for both hand span and hand length from the first assessor's first assessment were used to determine the normative between-hand difference. Outliers were removed prior to determining the normative difference. Children were considered outliers if their between-hand difference in hand span and/or hand length was in the top 5% of values.

RESULTS

Excellent reliability was established for hand span and hand length measures for the whole group (intra-rater ICC_2,1 ≥0.95, inter-rater ICC_2,1 ≥0.94). The mean normative between-hand difference for both measures was 2 mm. The cut-off for the normative difference in hand span was <9 mm and hand length was <6 mm.

CONCLUSION

This measurement technique has excellent reliability and could be a useful method to quantify palmar range of movement and identify contracture in young children with unilateral hand injuries.

Update on the practice of splinting during acute burn admission from the ACT study

INTRODUCTION

Burn scar contracture (BSC) is a common pathological outcome following burn injuries, leading to limitations in range of motion (ROM) of affected joints and impairment in function. Despite a paucity of research addressing its efficacy, static splinting of affected joints is a common preventative practice. A survey of therapists performed 25 years ago showed a widely divergent practice of splinting during the acute burn injury. We undertook this study to determine the current practice of splinting during the index admission for burn injuries.

METHODS

This is a review of a subset of patients enrolled in the Burn Patient Acuity Demographics, Scar Contractures and Rehabilitation Treatment Related to Patient Outcome Study (ACT) database. ACT was an observational multicenter study conducted from 2010-2013. The most commonly splinted joints (elbow, wrist, knee and ankle) and their 7 motions were included. Variables included patients' demographics, burn variables, rehabilitation treatment and hospital course details. Univariate and multivariate analysis of factors related to splinting was performed. P< 0.05 was significant.

RESULTS

Thirty percent of the study population (75 patients) underwent splinting during their hospitalization. Splinting was associated with larger burns and increased injury severity on the patient level and increased involvement with burns requiring grafting in the associated cutaneous functional unit (CFU) on the joint level. The requirement for skin grafting in both analyses remained independently related to splinting, with requirement for grafting in the associated CFU increasing the odds of splinting 6 times (OR =6.0, 95% CI=3.8-9.3, p<0.001). On average splinting was initiated about a third into the hospital length of stay (LOS, 35 ± 21% of LOS) and splints were worn for 50% (50 ± 26%) of the LOS. Joints were splinted for an average 15.1 ± 4.8 hours a day. The wrist was most frequently splinted joint being splinted with one third of wrists splinted ( 30.7%) while the knee was the least frequently splinted joint with 8.2% splinted. However, when splinted, the knee was splinted the most hours per day (17.6 ± 4.8 hours) and the ankle the least (14.4 ± 4.6 hours). Almost one third had splinting continued to discharge (20, 27%).

CONCLUSIONS

The current practice of splinting, especially the initiation, hours of wear and duration of splinting following acute burn injury remains variable. Splinting is independently related to grafting, grafting in the joint CFU, larger CFU involvement and is more likely to occur around the time of surgery. A future study looking at splinting application and its outcomes is warranted.