Functional and Aesthetic Reconstruction of Burn Patients

482
Functional and Aes thetic Recons truction of Burned Patients
Figure 35.5
Pictorial diagram of the start of the dissection of
the great toe. After identification of the digital artery bifurcation
in the first web space, retrograde dissection is undertaken to
determine dominance between the first dorsal metacarpal artery
and the first plantar metacarpal artery.
A specific sequence is followed in completion of the trans-
fer process.
Bone fixation may be achieved by doweling in distal toe
to distal digit transfers. The recipient finger phalanx is
tapered like a pencil and fit into the medullary cavity of
the toe phalanx. If the stump of the recipient finger or
toe phalanx is >5 mm from the adjacent joint, fixation is
achieved by applying interosseous wiring. Although not
Figure 35.6
Harvest o f a trimmed great toe.
rigid, this fixation is stable enough for early passive
range of motion exercises. Correction of any improper
positioning during the early postoperative period is also
possible with wire fixation technique (17,18).
Extensor tendon repair under tension is performed
before flexor tendon coaptation with the corresponding
tendons of the recipient digit. If a lesser toe is transferred,
the extensor tendon is repaired in full extension. To avoid
extension lag, the toe is kept in extension with a k-pin
through the interphalangeal joint for 3 weeks.
Following completion of osteosynthesis and tendon
repair, the nerves are coapted with 10-0 or 11-0 nylon
epineurial sutures under the microscope. The artery and
vein are anastomosed with 10-0 nylon interrupted sutures
and patency as well as distal perfusion checked prior to
wound closure.
In all kinds of toe transfers, the donor site should be
closed primarily without tension. Weight-bearing ambu-
lation on the foot is postponed until healing of the
wound is complete. Although preservation of at least
1 cm of the proximal phalanx of the great toe is crucial
for foot function, the lesser toes may be removed at the
metatarsal level without significant adverse effect on
either function or appearance.
D.
Functional and Aes thetic Modifications
in Toe Trans fers
Aesthetic challenges faced by toe transfers include the size
discrepancy between the digits of the foot and hand, lesser
toe clawing deformity as well as a bulging interface
between donor and stump. At its widest point, the great
toe on average is 11-13 mm wider than the thumb (17).
The trimmed-toe technique as described by Wei et al.
(18) addresses this issue adequately. A longitudinal osteo-
reductive resection of 4 -6 mm of bone is undertaken after
raising a hemicircumferential subperiosteal flap including
joint capsule and medial collateral ligament (Figs. 35.7-
35.9). This has the added benefit of retaining a medial
skin strip that allows avoiding the use of skin grafts to
close the donor site after toe harvest. One caveat with
this technique, however, is the reduction of about 18° of
interphalangeal joint motion, which in the majority of
patients does not result in any noticeable functional dis-
turbance (18). Additional reduction of the bulky pulp of
the great toe or of the lesser toes is usually undertaken sec-
ondarily by a wedge excision at the midline (Fig. 35.10).
Discrepancy of the size at the interface between donor
and recipient stumps may lead to a noticeable unsightly
junction. To minimize such a deformity, four flaps are
created on the amputation stump of the recipient, which
are undermined sufficiently and thinned. This allows a tel-
escoping effect of the toe over the stump. The neurovascu-
lar bundles of the harvested toe are skeletonized to allow

Thumb and Finger Reconstruction
483
Figure 35.7
The interphalangeal joint is exposed by raising a
capsulo-collateral ligament-periosteal flap from the dorsal
surface of the great toe infero-laterally.
passage through the skin tunnels and primary closure of
the recipient site wound. Although the overall appearance
of the reconstructed digits is improved significantly by this
method, occasionally the need for further debulking
develops (Fig. 35.11).
E.
Dis tal Digit Recons truction with Various
Tis s ues from the Foot
Whereas skin grafts, and local flaps provide coverage, they
are unable to restore digital length, nail function, adequate
soft tissue padding or functional sensation. Anatomically,
the most suitable source for “reproduction” of the
distal digit, besides the hand itself, is the foot. If a clean
interface exists between healthy and devitalized tissue,
reconstruction can be performed while the wound is still
Figure 35.8
After removal of the lateral one-third of the pha-
langeal width using an oscillating saw.
Figure 35.9
The capsulo-collateral ligament-periosteal flap is
trimmed and resutured to the dorsal edge in a tight fashion to
provide stability to the lateral aspect of the joint.
open. Otherwise, reconstruction is undertaken after the
wounds heal.
1.
Pulp
Sizable volar defects of the distal digits require restoration
of bulky and sensate tissue to allow for proper prehensile
function. To this end, glabrous skin from the great toe
hemipulp or the first web space of the foot is ideal. Even
if adjacent fingers require resurfacing, the pedal first web
space can be extended to include the adjacent hemipulps
or alternatively the medialis pedis flap can be transferred.
The resultant syndactyly is divided 3 weeks later, whereas
the donor site is either closed primarily or grafted with skin
from the inset of the foot.
Figure 35.10
Long-term appearance of the trimmed great toe
transfer to reconstruct the left thumb in comparison to normal.

484
Functional and Aes thetic Reconstruction of Burned Patients
Figure 35.11
After survival of the transferred toe, if the pulp
appears too bulky, a longitudinal wedge resection at the midline
usually gives an excellent cosmetic outcome.
2.
Nail
The absence of the nail complex interferes with function of
the finger to moderate extent, however, aesthetic concerns
dominate when considering nail transfers from the foot.
This can be accomplished by including a minimum of
dorsal skin to allow for arterial and venous provisions. Fur-
thermore, the dorsal cortex of the distal phalanx is included
to prevent injury to the nail matrix. Shortening the toe may
be necessary to allow for primary closure of the wound.
3.
Composite
When the burn has led to injury of the distal digit affecting
the pulp, skin, and nail, then a similar segment of tissue
can be transferred from the toe. The best method for recon-
structing a dorsal hemi-circumferential loss of soft tissue
and nail of the digit distal to the sublimes insertion with
intact skeleton and tendons is the toe wrap-around flap
(19,20). To prevent swiveling instability and bone resorp-
tion of the fingertip, the distal phalanx of the toe is always
included (21).
F.
Th um b Recons truction
Severe bum injury of the thumb resulting in significant
structural loss can be reconstructed by four main toe
transfer techniques; total great toe, second toe, great toe
wrap-around, and trimmed great toe. Each method has
its indication to restore a functional and aesthetic thumb
yet yield minimal donor site morbidity.
1.
The total great toe transfer provides a broad, strong
and stable surface area for pinch and grasp,
however, lacks precise fine pinch and manipu-
lation.
Furthermore, with exception to rare
instances, the great toe is usually much larger
than the thumb and therefore cosmetically objec-
tionable (18) (Fig. 35.12).
2.
The great toe wrap-around procedure is reserved
for patients with thumb amputation distal to the
interphalangeal joint or with only soft tissue and
nail defects, but intact bone, joint, and tendons.
When used in conjunction with an iliac bone
graft to reconstmct the entire thumb as originally
described, however, problems such as bone frac-
ture, proximal phalangeal resorption and pulp
swiveling may arise (21).
3.
The trimmed great toe transfer technique involves
reduction of both skeleton and soft tissue. It pro-
vides an ideal restoration of the thumb with good
function and
appearance
(18).
The modest
reduction in interphalangeal joint mobility has
been an accepted tradeoff for the significant
improvement in appearance.
4.
The second toe is another option for thumb recon-
struction, however, it provides less satisfactory
functional and aesthetic match to the thumb
because of its relatively small size and claw
appearance. It can be reserved for patients who
have a sizable second toe or those who object to
the sacrifice of their great toes (Fig. 35.13).
Figure 35. 12 Appearance of the total great toe after transfer
in contrast to the slimmer normal thumb. Note the wider,
bowling pin appearance of the total great toe on the right.

Thumb and Finger Recons truction
485
toe to hand transfers over the past two decades. During
the period of 1984-2001, a total of 1440 cases of micro-
surgical transfers from the foot to the hand have been
undertaken with burn injury as one of the many indications
(Table 35.3).
XI.
POSTOPERATIVE CARE
Postoperative management is focused on assuring survival
of the transferred tissue without neglect of the general care
of the patient. This entails maintaining body and flap temp-
erature, fluid balance, hemodynamics, pain control, atrau-
matic wound care, and above all intensive flap monitoring.
Several monitoring methods are available based on the
preference or capability of each center. In high volume
microsurgical centers such as ours, a microsurgical inten-
sive care unit provides an ideal setting for close and accu-
rate monitoring of transferred tissue based on physical
examination and pulse oximetry. Evaluation of skin
color, temperature, capillary refill, and turgor by experi-
enced personnel obviates the need for expensive equip-
ment. Re-exploration should be undertaken in a more
aggressive manner for any significant change in perfusion
characteristics. If it appears that wound closure was too
tight, sutures should be removed at bedside and biological
dressings applied as needed. Salvage is possible in about
80% of compromised toe transfers in our experience.
Patients are usually discharged from the hospital 5 days
after surgery.
XII.
REHABILITATION
After resurfacing procedures, mobilization is restricted
only for the first few days until stable circulation has
been established. Physical therapy is then gradually pro-
gressed to maximize the range of motion. Pins are
Table 35. 2
Classification of the Metacarpal Hand According to Wei et al. (23)
TPE-subtype
Level of finger amputation
Recommendations for reconstruction
1 A
Distal to MCPj
1. Bilateral second toes for amputations distal to the web space
2. Combined second and third toes for amputations proximal to
the web space
1 B
Through MCPj with intact MC articular surface
Combined second and third toes (Composite joint transfer)
1 C
Damaged metacarpal articular surface
Combined second and third toes (transmetatarsal transfer)
II
Thumb
II A
Distal to MCPj with thenar muscles intact
Simultaneous finger and thumb reconstruction
II B
Through or proximal to the MCPj with intact thenar
muscles
Same as above
IIC
Through or proximal to the MCPj with inadequate
Thumb reconstruction in a second stage after finger
thenar muscles
reconstruction
II D
Damaged CMCj
As above, but develop immobile thumb post
Note: MCPj, metacarpophalangeal joint; MC, metacarpophalangeal; CMCj, carpometacarpal joint.
Figure 35. 13 Appearance after use of the second toe for
thumb reconstruction. It is obviously much smaller than the
normal thumb, and is used in cases where the great toe is not
available or the patient refuses its loss.
G.
Metacarpal Hand Recons truction
The challenge of reconstructing the hand with missing mul-
tiple digits due to burn injury is addressed first by appropri-
ate identification of what is “functionally” missing. For
example, if the ring and small fingers are missing, the func-
tional deficit of the hand is minimal unless complex tasks
are required. However, the presence of just an index
finger requires a thumb as well as another finger for basic
triple pinch function. The complexity of the possible clinical
presentations of multiple digit injury to the hand is classified
with recommended reconstructive methods in Table 35.2.
H.
Clinical Experience with Toe Trans fers
The microsurgical service at Chang Gung Memorial
Hospital in Taiwan has gained significant experience of

486
Functional and Aes thetic Recons truction of Burned Patients
Table 35.3
Clinical Experience with Toe to Hand Transfers at
Chang Gung Memorial Hospital During the Period 1984-2001
usually removed 3-4 weeks after placement, and splints
are utilized for wound protection or maintenance of
digital position. For example, if a clawing disposition of
a transferred lesser toe is noted, nocturnal extension
splints are instituted for up to a year, if necessary (17).
After partial toe transfers, such as the pulp or nail
complex, motor rehabilitation is not complex since
tendon manipulation is absent. Sensory re-education is
the focus of rehabilitation, and training is initiated when
the patient is able to perceive 30 cycles/s vibrations
from a tuning fork (17). Discrimination of size and
shape as well as object identification then becomes the
goal of sensory re-education during the late phase.
Total toe transfers on the other hand undergo a five-
stage rehabilitation program (17). The therapist for the
first 3 days helps observe viability of the flap and gives
psychological support to the patient. Starting on day 4
gentle passive range of motion of the joints and more
active assistance of uninvolved fingers are undertaken
for 3 weeks in order to control edema and prevent joint
stiffness. Protective splinting is utilized during this
period, and is useful in correction of any problems with
maintaining proper axis and rotation. Gentle active exer-
cise is begun during the third stage (week 5-6) in conjunc-
tion with the use of a dynamic splint. Scar management
and gait training is active during this period as well. As
further improvement of the muscle power and range of
joint motion is noted during the ensuing week, tasks simu-
lating daily living activities are instituted. After the eighth
week, the potential vocational activity of the patient is
assessed and additional exercises are recommended
based on a complete evaluation of the strength, dexterity,
and coordination of the reconstructed digit, in addition to
the hand as a whole.
XIII.
OUTCOME OF FREE TISSUE
TRANSFER IN BURNED HAND
A.
Early Period
Results following tissue transplantation during the initial
period are primarily based on local factors such as tissue
survival and wound healing. Systemic complications are
rare. In general free flap survival rates are 95-100%, and
indeed toe transfers are no exception (4,17,22). Although
donor site problems are infrequent, open wounds of the
foot pose a significant challenge to normal healing.
B.
Long-term
In contrast to the initial period, the measure of success of
any reconstructive effort involving the hand is the restor-
ation of mobility, strength, sensibility, and appearance in
comparison to normal. Following resurfacing procedures,
Woo and Seul (5) noted that range of motion improvement
for palmar contractions were poor. In contrast, dorsal or
first web space resurfacing was associated with significant
improvement in range of motion of previously immobile
digits. A total range of motion of all joints was 85° on
average with improvement recorded in mean grip strength
and key pinch in 16 of 18 patients in their series (5). Evalu-
ation of toe transfers on the other hand, is dependent upon
the method of reconstruction. In their series of 45 thumb
reconstructions, Wei et al. (18) were able to evaluate
results in three techniques. Second toe transfer undertaken
in 10 patients resulted with an average two-point discrimi-
nation of 13 mm, grip strength 60% of normal, and key
pinch 40% of normal. The range of motion at the level
of the distal interphalangeal joint was 0°-5° and the prox-
imal interphalangeal joint ~25°. The great toe wrap
around among 15 patients yielded a two-point discrimi-
nation of 12 mm, grip strength 75% of normal, key
pinch 80% of normal, and interphalangeal joint motion
of 40°. Finally, 20 patients who underwent trimmed
great toe transfers resulted with a two-point discrimination
of 13 mm, grip strength 66% of normal, key pinch 75% of
normal and interphalangeal joint motion of 20° (17).
Although, the great toe atrophies by 10-15% within the
first 3 years after transfer, it still remains conspicuously
large and cosmetically unacceptable (18). The trimmed
toe technique provides the most ideal cosmetic appearance
compared to all other methods currently available.
C.
Donor Site
Donor morbidity following resurfacing procedures is
usually minimal and straightforward. Similarly, partial
toe transfers such as the nail or pulp is well tolerated.
Larger structural toe transfers, however, may result with
significant foot deformity or gait problems if proper proto-
col is not observed during surgery. Whereas the lesser toes
may be disarticulated at the metatarsal level without any
significant effect on gait and even appearance, the great
toe requires a minimum of 1 cm of its proximal phalanx
preserved (18). As such the overall function of the foot
is maintained, although there may be some impairment
in pedal push-off and speed during running or walking
on uneven terrain. Incisions on the plantar surface of the
Partial toe
Single toe
Combined toes
Joint
49
Great Toe
188
2nd/3rd
160
Pulp
109
2nd Toe
774
3rd/4th
3
Wrap-around
116
3rd Toe
37
4th Toe
4

Thumb and Finger Reconstruction
487
foot usually heal very well, although the dorsal foot scar
frequently heals with varying degrees of hypertrophy.
Improper closure methods may result in wound dehis-
cence, which result in major problems to the patient due
to chronicity and are best avoided.
XIV.
CONCLUSION
The hand requires proper functioning digits to play its
central role in our daily lives. Given its frequent exposure
to the external world, the hand is also subject to various
forms of injury including burn injury, which can result
in variable depths of injury. Initial management methods
by the physician and patient as well as the inherent
wound healing characteristics of the patient determine
the outcome of the injured hand. The resulting myriad of
clinical presentations defies classification, and manage-
ment of such difficult conditions requires adherence to
basic principles. Whereas during the initial periods after
injury preservation of tissues and motion is of prime
importance, during the late, chronic stages it is that of
radical release of cicatricial contractures and accurate res-
toration. In comparison to existing methods of reconstruc-
tion, free tissue transfer is best able to accomplish the goal
of restoration by providing a “replica” from the foot of
what is missing. In final analysis however, complete res-
toration of both aesthetic and functional characteristics
of the hand is yet to be achieved, therefore our vigilance
in searching for better ways to manage these difficult
cases should continue unabated.
REFERENCES
1.
Zook EG. The périonychium. Clin Plast Surg 1981;
8:21-31.
2.
Bunnell S. Physiological reconstruction of a thumb after
total loss. Surg Gynecol Obstet 1931; 52:245.
3.
Littler JW. On making a thumb. J Hand Surg 1976; 1:35.
4.
Asko-Seljavaara S, Pitkànen J, Sundell B. Microvascular
free flaps in early reconstruction of burns in the hand and
forearm. Scand J Plast Reconstr Surg 1984; 18:139-144.
5.
Woo S-H, Seul J-H. Optimizing the correction of severe
postburn hand deformities by using aggressive contracture
releases and fasciocutaneous free-tissue transfers. Plast
Reconstr Surg 2001; 107:1-8.
6.
Beasley RW. Secondary repair of burned hands. Hand Clin
1990; 6:319.
7.
Kolar J, Vrabek R. Periarticular soft tissue changes as a
late consequence of bums. J Bone Joint Surg 1959;
41A:103-111.
8.
Salisbury RE. Reconstruction of the burned hand. Clin Plast
Surg 2000; 27:65.
9.
Krizek TJ, Robson MC, Headley BJ. Management of burn
syndactyly. J Trauma 1974; 14:587-593.
10.
Wei F-C, Colony LH. Microsurgical reconstruction of
opposable digits in mutilating hand injuries. Clin Plast
Surg 1989; 16:491.
11.
Honda T, et al. The possible applications of a composite
skin and subcutaneous vein graft in the replantation
of amputated digits. Br J Plast Surg 1984; 37:607-612.
12. Kantarci U, Cepel S, Gurbuz C. Venous free flaps for recon-
struction of skin defects of the hand. Microsurgery 1998;
18:166-169.
13.
Samson MC, Morris SF, Tweed AE. Dorsalis pedis flap
donor site. Plast Reconstr Surg 1998; 102:1549.
14. Woo S-H, Jeong J-H, Seul J-H. Resurfacing relatively large
skin defects of the hand using arterialized venous flaps.
J Hand Surg (Br) 1996; 21:222.
15.
Logan A, Elliot D, Foucher G. Free toe pulp transfer to
restore traumatic digital pulp loss. Br J Plast Surg 1985;
38:497.
16.
Akizuki T, Harii K, Yamada A. Extremely thinned inferior
rectus abdominis free flap. Plast Reconstr Surg 1993;
91:936.
17. Flatt AE. Digital artery sympathectomy. J Hand Surg 1980;
5:550.
18. Wei F-C et al. Microsurgical thumb reconstruction with toe
transfer. Plast Reconstr Surg 1992; 93:345.
19. Wei F-C et al. Reconstruction of the thumb with a
trimmed-toe transfer technique. Plast Reconstr Surg 1988;
82:506-513.
20. Morrison W, O’Brian MC, Macleod M. Thumb reconstruc-
tion with a free neurovascular wrap-around flap from the
big toe. J Hand Surg 1980; 5:575.
21. Wei F-C et al. Second toe wrap around flap. Plast Reconstr
Surg 1991; 88:837.
22. Leung PC. Problems in toe-to-hand transfers. Ann Acad
Med 1983; 12:377.
23. Wei F-C et al. Metacarpal hand: classification and guide-
lines for microsurgical reconstruction with toe transfer.
Plast Reconstr Surg 1997; 29:122.

(Trang không có chữ)

36
Rehabilitation of the Burned Hand
MICHAEL SERGHIOU, ALEX McLAUGHLIN
Shriners Hospital for Children, Galveston, Texas, USA
489
I.
In tro d u c tio n
4 9 0
9 -
“Fig u re 8” S w a n -Ne c k S p lin t
501
A.
E va lu a tio n o f the Bu rn e d Ha n d
4 9 0
10.
Bo u to n n ie re De fo rm ity Dig ita l
1.
His to ry o f P re s e n t Illn e s s
4 9 0
G u tte r S p lin t
501
2.
Me d ic a l/S o c ia l His to ry
4 9 0
U - Ma lle t De fo rm ity F in g e r S p lin t
502
3.
Wo u n d s
4 9 0
12. “Ba rre l S p lin t”
502
4.
Edema
490
13. Thumb CMC Antideformity Splint
503
5. Range of Motion
490
B. Dynamic Splints for the Burned Hand
503
6.
Strength
491
1- Hand MCP/IP Flexion Splint
503
7.
S o ft Tis s u e Tig h tn e s s
491
2. Ha n d M C P /IP Exte n s io n S p lin t
5 04
8.
S e n s atio n
491
3. Dig ita l Dyn a m ic F le x io n /
9.
Ac tivitie s o f D a ily Liv in g
491
Exte n s io n S p lin ts
505
10. Tre a tm e n t P la n
491
C.
S e ria l Cas ts
505
II.
E d e m a Ma n a g e m e n t
491
D ‘
S ke le ta l Tra c tio n an d Su s p en s io n
507
TTT
E.
Active Range of Motion
507
natomy
P
Passive Range of Motion
509
IV. Orthotics
496
q
Prolonged Stretch
509
A.
Static Splints for the Burned Hand
497
H
Joint Mobilization and Tendon Gliding
510
1. Antideforaiity Burn
j
gcar Management of the Burned Hand
510
Hand Splint
497
L Pressure Therapy
510
2.
Resting Pan Extension
j
Physical Agent Modalities Utilized
Splint (Palmar)
497
-n g urn Hand Scar Management
513
3.
Sandwich Splint
498
K
Scar Massage
514
4.
Digital Gutter Splints
499
^
^
.
C1/l
V.
Capsulotomy
514
5.
Wrist Splint
499
.
6.
Firs t W e b C -B a r S p lin t
5 0 0
VL
A m Pu ta tlo n s
515
7.
Th u m b S p ic a An tic u p p in g S p lin t
5 0 0
V II. S u m m a ry
515
8.
Dorsal MCP Block Splint
500
References
515

490
Functional and Aes thetic Recons truction of Burned Patients
Burn rehabilitation is a challenging undertaking and in
order for it to be successful it requires, among other
medical professionals, the expertise of a therapist who pro-
gresses the patient along the continuum of care using
appropriate interventions.
It is especially critical to manage bum injuries to the
hands expeditiously, efficiently, and correctly in order to
achieve a positive functional outcome at the completion
of the rehabilitative process. Even the most devastating
hand bum injury can produce a respectful functional
outcome when managed by a knowledgeable interdisci-
plinary bum team. Selecting the best therapeutic interven-
tions at the correct time prevents hand contractures and
deformities which would result in a less desirable func-
tional outcome.
Though bum injuries frequently involve other body
surface areas in addition to the hands and affect the
patient physically as well as psychologically, this
chapter focuses on the management of hand burns and
addresses all components of therapy from the emergent
phase of recovery to the completion of the rehabilitative
process. This chapter provides useful guidance for new
and experienced therapists attempting to treat hand burns
injuries.
A.
Evaluation of the Burned Hand
A comprehensive hand evaluation should be conducted as
soon as possible after the injury by an experienced thera-
pist in order to assess the patient’s needs and develop a
thorough plan of care (1). It is imperative that the therapist
performs and documents an accurate physical examination
of the patient and gathers all pertinent data needed to
develop a quality treatment plan (2-4). A hand evaluation
should include the entire upper extremity involved in the
assessment and not separate the hand from the wrist,
forearm, elbow, and shoulder as the entire extremity
works in unison to produce a functional task. Assessing
the contralateral uninvolved extremity provides baseline
data for developing goals and treatment plans for the
patient.
1.
History of Present Illness
Gathering as much information from the patient and/or
their family about the accident is crucial. First, it is import-
ant for the therapist to “paint” a mental picture of how the
accident occurred and what caused it (etiology). Any
associated injuries such as smoke inhalation, tendon/
joint exposure, and fractures should be recorded in the
medical record.
I.
INTRODUCTION
2.
Medical/ Social History
Age, previous level of function, occupation, hand domi-
nance, family support, and other significant social
history information may be collected by the therapist in
an interview fashion with the patient and/or family (5).
During this difficult and stressful time the patient or their
family may ask about the patient’s future functional
level (i.e. returning to previous working environment,
pursing a new career, etc.). Any significant past medical
history should be documented in the evaluation. All pre-
vious operative procedures should be included in the
history component of the outpatient evaluation.
3.
Wounds
The wound location and depth are relevant to the rehabili-
tation therapist and require careful assessment. Photo-
graphs and diagrams may be used to record the hand
wounds. Superficial partial-thickness burn injuries rarely
require splinting and exercises begin immediately. Deep
partial- and full-thickness injuries need to be positioned
correctly to prevent contracture development (6). The
location of wounds and their severity may hinder the
initiation of exercises during the inflammatory phase of
wound healing. During the evaluation process the therapist
and physician should determine the most appropriate
wound dressing which allows movement and functional
use of the hand. Exposed tendons or joints need to be pro-
tected through immobilization in order to prevent further
injury (7).
4.
Edema
Acute edema is a natural response to injury. The inflamma-
tory phase (~0-72 h after injury) is part of the already
begun wound healing process (8). In the case of circumfer-
ential burn injuries involving the hand, edema may be so
severe that an escharotomy may be warranted to prevent
ischemia and necrosis of the digits (9,10). During the
emergent phase when the edema is acute and pronounced,
measurements may be grossly performed. As edema
begins to subside and the patient progresses to the acute
phase of the recovery process, any persisting edema
needs to be assessed and closely monitored. After wound
closure, edema in the hand may be assessed utilizing the
volumeter technique or by measuring the circumferences
of the digits utilizing a tape measure (11-16). Ongoing
assessments and accurate documentation of edema
would track the patient’s progress and guide therapeutic
interventions thus preventing further injuries to the hand.
5.
Range of Motion
Initially edema, pain, and multiple open areas may signifi-
cantly affect the patients’ ability to move their hand

Rehabilitation of the Burned Hand
491
functionally. Baseline goniometric measurements are
recorded and used later to track range of motion (ROM)
improvement. Later, an in-depth goniometric evaluation
should be conducted utilizing a standard methodology in
recording all measurements so that communication of
findings will be fluent among therapists and physicians
(17-20). It is important for the therapist to regularly
track active ROM, passive ROM, and total active motion
(TAM) in order to make progress projections and
develop appropriate plans to ensure optimal outcomes
(21,22).
6.
Strength
A baseline strength assessment should be performed as
soon as the patient’s medical status allows. Strength
goals are designed based on the patient’s probable dis-
charge environment and functional requirements. Initially,
a manual muscle test is conducted for the entire upper
extremity (17,22,23). Later, a dynamometer and pinch
gauge can also be used to assess grip and pinch strength
(17,22-28).
7.
Soft Tissue Tightness
A thorough physical examination of the hand includes an
assessment of soft tissues. Range of motion limitations
may be due to ligament, joint, tendon, or skin tightness.
Each offending tissue is addressed separately in the treat-
ment plan (4,7,29).
8.
Sensation
Sensory re-education of the burned patient who sustained a
significant upper extremity burn injury involving the hand
poses a challenge to the rehabilitation team. Acutely, a
formal evaluation of sensation may not be possible sec-
ondary to the presence of wounds, dressings, or nerve
injury. As the patient progresses to the acute and rehabili-
tation phases of recovery, wounds are closed and a
thorough sensory evaluation may be performed (30,31).
An electrical injury to the upper extremity is often devas-
tating to the sensation of the hand. A thorough sensory test
is conducted in these cases in order to track the patient’s
sensory recovery.
One objective way to measure
cutaneous sensibility is the use of Semmes-Weistein
monofilaments
(33-37).
Two-point
discrimination
testing assesses the patient’s functional hand sensibility
as it relates to the ability to perform fine tasks (38-41).
Protective sensation such as heat, cold, and superficial
pain such as the pin prick test should also be tested. Skin
graft type, depth of wounds, scar hypertrophy, and the
stage of scar maturation should be taken into account
during the sensory evaluation (42-44). Functional tests
such as the Dellon modification of the Moberg pickup
test could be used during sensibility testing (44).
9.
Activities of Daily Living
Prior activities of daily living (ADL) status and previous
occupation as well as the patient’s future vocational
goals are documented and considered in developing
long-term treatment plans. The patient’s current ADL
status is assessed including mobility, feeding, grooming,
dressing, bathing, toileting, and functional goals are devel-
oped that address ADL performance.
Other information that should be gathered during the
initial evaluation of the patient includes an inventory of
existing splints, inserts, pressure garments, and home exer-
cise programs, which will be addressed later in this
chapter.
10.
Treatment Plan
Once all the objective components of the evaluation are
completed, the patient, his or her family, and the therapist
should develop specific meaningful and functional goals
that address the patient’s needs. A comprehensive plan
of care that addresses all the developed goals is then devel-
oped. A complete report of the evaluation findings and
plan of care should be sent to the patient’s physician for
review and approval prior to initiating treatment.
The status of the burned hand will continue to change
for as long as all scars are active and operative procedures
occur. Frequent reassessments are needed as conditions
change and short-term goals are met. New goals and
plans of care are developed as needed. At the conclusion
of treatment, an impairment rating evaluation can be per-
formed to calculate to percentage of permanent functional
deficits in the hand (19,45).
11.
EDEMA MANAGEMENT
Acute trauma from a burn injury results in edema to the
affected area. The deleterious effects of this necessary
response to trauma are most obvious in the compact and
crowded space of the hand. Superfluous fluid in the hand
and fingers is caused by an increase in vascular per-
meability. This reduces longitudinal freedom of the
tendons passing anterior and posterior to the metacarpal
phalangeal and interphalangeal joints. Hunter (13) also
states that edema causes loss of the transverse and longi-
tudinal hand arches. This posture of “palmar planus” can
also be caused by the presence of scar tissue on the
dorsal surface of the hand. The resulting pain with move-
ment allows stiffness to develop quickly without proper
attention from a rehabilitation therapist.

492
Functional and Aes thetic Recons truction of Burned Patients
In order to prevent stiffness after trauma, early motion
has been advised by many authors. Movement, when
begun early, assists in edema reduction, maintains
normal tendon gliding, and normalizes flow of toxic
waste out of, and nutrients into, the joint capsule
(8,13,46). Exercise can begin almost immediately in extre-
mities having partial-thickness bums. However, full-thick-
ness bums, and deep partial-thickness bums requiring skin
grafts must be immobilized for 4 -6 days to allow graft
adherence. This also applies to burn scar contractures
being released in the reconstructive phase.
At the conclusion of the operative procedure the phys-
ician applies a bulky compressive dressing. A bolster or
small bulky compressive dressing limited to the surgical
or injury sight can be used to control bleeding and
edema. Care should be taken to maintain separation of
the web spaces and the hand should be wrapped to
promote the intrinsic plus or fisted position (8,47)
(Fig. 36.1). In some cases the surgeon may request a
splint to be applied intraoperatively to promote correct
positioning of the hand. When a splint is used, it is best
applied with minimal dressing on the hand. However, if
a large wrap is present, Richard et al. (48) provide a
formula that accommodates for a bulky dressing when fab-
ricating a bum resting hand splint. Clinically, excellent
results have been observed when splints are applied
intraoperatively.
Postoperatively, elevation above the level of the heart
cannot be stressed enough to the patient and hospital
staff. This can be accomplished with pillows, overhead
slings, bedside tables, or arm troughs (Fig. 36.2). Isometric
exercise is also helpful in activating the muscle pumping
mechanism to remove excess fluid. However, isometric
contraction of the intrinsic muscles of the hand is a difficult
concept for many patients to grasp; and should not be part
of treatment during postoperative immobilization if con-
traction of the small hand and forearm muscles cannot
occur without associated movement at the wrist and
fingers. Graft integrity is more easily preserved when
intraoperative splints are used in conjunction with iso-
metric exercise. Young children are not able to cooperate
with isometric exercise.
After the bulky bandages are removed by the physician
and dressed in a thin antibiotic dressing, the edematous
hand and fingers are wrapped in a Coban™ glove
(Fig. 36.3). This compressive elastic wrap allows free
motion while assisting with edema reduction (49). The
wrap is applied to each affected finger distal to proximal.
The palm and web spaces should also be wrapped if
involved as well. Care should be taken to leave no
exposed hand surface where fluid might accumulate.
The first few days after the bulky dressing is removed,
elevation should continue. This can be accomplished
through the use of arm slings or by simply asking the
patient to keep the hand elevated above the heart when
walking. Slings are often inefficient because few patients
wear them properly due to noncompliance or poor edu-
cation. When sitting, patients can use pillows or tables to
assist with elevation. Moreover, functional activities and
intermittent exercise should be incorporated throughout
the patient’s day. Children are sometimes difficult to
engage in play activity due to anxiety related to pain.
The importance of a supportive but firm caregiver is
very important at this stage. Anxiety is not exclusive to
children, however, and a supportive care network is
equally important to adults. In cases where pain and
anxiety interfere with rehabilitation and daily tasks, con-
sulting pain specialists is helpful.
Figure 36.1
Web spaces are separated with gau ze and the intrinsic plus splint is bein g applied in traoperatively.

Rehabilitation of the Burned Hand
493
Figure 36.2
Arm troughs may be utilized at the bedside to elevate the grafted extremity above the level of the heart.
Caregivers, patients, and staff can be instructed in
gentle retrograde massage. This type of massage, when
used prior to exercise or activity is especially helpful in
hands with moderate to severe edema. Scarring will
begin to form in 2 -4 weeks, at this time the skin will tol-
erate a compression glove. Gloves can be either prefabri-
cated or custom-fit. Custom-fit gloves provide higher
compression, but require specialized training for measure-
ment and fitting, and are also more expensive than prefab-
ricated gloves. There are several manufacturers of pressure
garments and their products are available throughout the
world.
Unfortunately, chronic edema does develop in some
cases. Causes are poor patient compliance, delayed refer-
ral for therapy, or in the more severe wounds, damage to
the lymphatic drainage system of the upper extremity.
Most often chronic edema seems to result when two or
more of these factors are present. The limited ROM that
results will greatly decrease the patient’s independence,
concurrently increasing the burden of care on the family.
Patients such as this require a very aggressive approach
using all of the previously mentioned treatment interven-
tions. Sequential intermittent compression pumps have
been utilized for burns. Ause-Ellias et al. (50), in a
Figure 36.3
Coban™ is wrapped sequentially to provide a thin bandage in which the patient can easily exercise. This prevents edema
and protects newly grafted skin from sheer forces.

494
Functional and Aes thetic Recons truction of Burned Patients
preliminary study of this modality, reported this modality
to be ineffective in reducing hand volume or improving
ROM in patients with chronic hand edema. If noncompli-
ance is suspected to be the primary cause of ongoing
edema, psychological intervention may be necessary.
III.
ANATOMY
The 27 bones of the hand, 28 muscles that insert upon
them, various sensory and motor branches of the median,
ulnar and radial nerves, and numerous ligamentous con-
nections combine to give us a tool capable of amazing
degrees of fine and gross motor movement. A detailed
study of this complex anatomy is well beyond the scope
of this chapter. Therefore, we will confine ourselves to
the practical anatomy that is most often affected by a
wound, and how the associated pathology might be
addressed through rehabilitation. Those areas include the
skin, interphalangeal (IP) joints and metacarpal-phalan-
geal (MCP) joints, and transverse metacarpal arches.
A mobile dermis layer, which averages < 2 mm thick
covers the dorsal surface of the hand and fingers (51).
This covering is quite thin compared to other regions of
the body and leads to several complications in the presence
of thermal injury. Take a moment to examine the skin of
your own hand. Unless you have experienced trauma,
which has resulted in major scarring, you will notice
folds of skin over the interphalangeal joints. Now flex
the fingers and notice how the skin stretches and unfolds
over the dorsum of the joint. At about 60° the skin has
to actually lengthen and at maximum flexion a slight
resistance to stretch can be felt and blanching at the joint
can be observed (52). In the burned hand that has experi-
enced at least a deep partial-thickness burn, scar tissue
tightens the normally loose dorsal skin, and can bind it
to the underlying soft tissue. This decreased skin mobility
will cause resistance to stretch much earlier than in the
hand unaffected by scarring. If the scar is severe, a limit-
ation in range of motion will also occur. This problem is
compounded in the pediatric population who often lacks
the muscle power necessary to overcome increased resist-
ance. Not to mention the pain that all persons will experi-
ence when stretching tightened skin. When left unopposed,
scar tissue will result in deformities of the joints that no
amount of muscle strength can overcome. Prevention of
these contractures is always the best treatment plan.
Appropriate splinting and exercise, which will be dis-
cussed later in the chapter, when done early and consist-
ently will almost assure that this problem will not occur.
As we go beneath the dorsal palmar skin we find the
superficial and supratendinous fascia. Underneath the
fascial layers lie the tendons of the extensor pollicis
brevis, abductor pollicis longus, extensor carpi radialis
longus and brevis, extensor pollicis longus, extensor digi-
torum, extensor indicis, extensor digiti minimi, and exten-
sor carpi ulnaris. Although any of these tendons could be
exposed given a deep enough burn, two stand out as the
most commonly damaged. The central slip of the extensor
digitorum and the terminal tendon at the distal interphalan-
geal (DIP) joint are the tendons most commonly damaged
in full-thickness bums, either by direct thermal injury, or
possibly through ischemia (53,54). Central slip damage,
whether partial or total, can upset the intricate forces
that balance the hand. Just distal to the insertion of the
central tendon lies the triangular ligament. If damage to
this ligament occurs a boutonniere deformity can result
without proper splinting (55). This deformity occurs
because the ineffective triangular ligament allows the
lateral bands to fall below the proximal interphalangeal
(PIP) joint flexion axis. If damage is isolated to the
central tendon an inability to extend the PIP joint occurs
Figure 36.4
Bou tonn iere deform ity.

Rehabilitation of the Burned Hand
495
Figure 36.5
Mallet finger.
without the formation of a boutonnière deformity
(Fig. 36.4). Rosenthal (56) recommends that conservative
treatment of damaged extensor slip and triangular liga-
ment include uninterrupted splinting for 6 weeks followed
by 4 weeks of splinting whenever exercise is not occur-
ring. Doyle’s (57) review of the literature also rec-
ommends 6 weeks of continuous splinting followed by
mobilization. Treatment would include digital gutter
splinting of the affected fingers in extension for 4 -6
weeks.
Exposure of the terminal tendon at its insertion to the
distal phalanx also can occur and result in a mallet finger
(Fig. 36.5). Treatment would include digital gutter splint-
ing of the affected fingers in slight hyperextension for 6-8
weeks (54,55,57). Honer (58) advocates continuous splint-
ing for 4 weeks followed by 4 weeks of limited flexion
during supervised therapy sessions. In the case of terminal
tendon damage, the commonly used Stack splints are often
ineffective due to the wound dressings required for bum
wounds. During this time the affected joint must not be
allowed to flex. Percutaneous pinning of the PIP or and
DIP joints may also be considered if bulky dressings or
noncompliant patients prove splints to be ineffective
methods of treatment (Fig. 36.6) (59). Boutonnière and
Figure 36.6
Kirschner wires have been inserted in this small pediatric hand after unsuccessful attempts to immobilize the exposed PIP
joints with the exposed PIP joints with gutter splints.

496
Functional and Aes thetic Recons truction of Burned Patients
Figure 36.7
Swan-neck deformity occurring due to a damaged transverse retinacular ligament or excessive dorsal scarring.
mallet fingers may also occur when scaring occurs anterior
to the joint action. If this is the case treatment is the same
as described earlier.
Swan-neck deformities sometimes occur when the
transverse retinacular ligament is damaged or when
heavy scaring is present posterior to the joint axis of the
PIP joint (Fig. 36.7). Salisbury et al. (53) suggest that
another cause of this contracture is ischemia to the intrin-
sic muscles of the hand. These swan-neck deformities
seem to be less common than those of the boutonnière
type. A posterior digital gutter, or Figure-8 splint is
often helpful in preventing these contractures when they
are identified early, and should be applied as soon as PIP
hyperextension is identified (60).
The MCP joints are often affected by scar tissue on the
dorsal aspect of the hand. Hyperextension deformities
often occur quickly and are quite difficult to correct if
not treated early (Fig. 36.8). When contracture occurs
the flexor tendons of the hand are placed at a mechanical
disadvantage that makes normal flexion difficult. Also
the collateral ligaments shorten along with the long exten-
sor tendons, which serves only to further inhibit flexion.
Treatment options include static and dynamic splinting,
serial casts, joint mobilizations, strengthening and
tendon gliding exercise, and heat modalities (60,61).
IV.
ORTHOTICS
Orthotics are an integral component of physical rehabilita-
tion and their use is vital in achieving positive functional
outcomes at the completion of bum hand rehabilitation.
Severe bums to the hand may affect structures such as
tendons, muscles, joints, nerves, and vessels in addition
Figure 36.8
Hyperextension deformity at the MCP joint will result in palmar planus significantly compromised mobility if not treated
aggressively.

Rehabilitation of the Burned Hand
497
to the destruction of the skin. The rationale for hand splint-
ing may include:
•
Edema reduction in the emergent phase (0-72 h
post injury)
•
Functional positioning to allow for movement and
performance of ADL
•
Protection of new skin grafts or flaps
•
Protection of exposed tendons or joints
•
Prevention or correction of contractures
•
Correction of joint alignment
•
Remodeling of scar tissue
•
Maintenance or improvement of ROM
•
Strengthening of weak muscles by exercising
against springs or rubber bands
•
Assisting weak or partially innervated muscles to
counteract the effects of gravity during function
(62-64).
The therapist must be aware of the anatomy and kinesi-
ology of the hand as well as the basic mechanical principles
of splinting when fabricating a splint (65). Correct use of
pressure distribution over a large body surface area, mechan-
ical advantage, torque, and rotational forces applied to the
splints would prevent pressure points, subluxation, dislo-
cation, and other injuries to the joints and surfaces treated.
It is imperative that splints are prevented from migrating
and shifting to avoid further injury. It is important to recog-
nize that once constructed and applied splints should:
•
not cause pain
•
be functional
•
be cosmetically appealing
•
easily applied and removed
•
be light weight and low profile
•
be constructed of perforated materials so that
wounds are not occluded
Having all these principles in mind during splint con-
struction should help improve the patient’s satisfaction
and compliance with all orthotics (63,64,66).
No matter how the bum therapist approaches splinting
(materials, designs, and application schedules) the goal
of bum rehabilitation is to achieve maximum function at
the completion of therapy. There are no “cookbook” pro-
tocols dictating when to splint, how to splint, how long
to splint, and what type of splint to construct. Generally,
in bum hand rehabilitation, splinting follows the path of
the wound healing phases and the ongoing physical
changes of the hand (67).
A.
Static Splints for the Burne d Hand
Therapists continue to debate whether splints are required
immediately after the injury to the hand. In general, a
superficial
second-degree
burn
(superficial
partial
thickness) to the hand would not require splinting. Move-
ment and performance of ADL are recommended immedi-
ately. In cases of significant edema presence a burn hand
splint may be indicated to position the hand appropriately
and aid in reducing edema. Deep bums that result in
tendon or joint exposure require immediate splinting and
immobilization at all times except in the presence of a
therapist. In the case of an electrical bum to the upper
extremity where peripheral nerve damage affecting the
function of the hand is suspected, the therapist should
splint and protect joints to prevent future hand stiffness
and deformities (3,8,62,68). Immediately postgrafting a
hand splint may be applied to position the hand appropri-
ately, protect the graft, and aid in the graft “take”.
1.
Antideformity Bum Hand Splint
The splint resembles the functional position resting hand
splint. It positions the wrist in 0-30° extension, the MCP
joints in 70-90° flexion, the interphalangeal joints
(proximal and distal) in full extension and the thumb in
a combination of carpometacarpal (CMC) joint palmar/
radial abduction (68,69) (Fig. 36.9). This splint prevents
extension contractures at the MCP joints caused by skin
and collateral ligament tightness and flexion contractures
of the PIP joints which result from skin and volar plate
tightness (64,66). In the case of deep injuries this position
must be maintained early on in rehabilitation as it reduces
the risk of hand stiffness later in therapy, maintains
tissues elongated, and directly relates to the functional
use of the hand. The splint should be worn in the cases
of deep partial- or full-thickness bum injury, when
joints or tendons are exposed, when the hand has suffered
peripheral nerve damage and when significant persisting
edema in the hand poses a threat for further injury. The
splint should be removed for exercises and the perfor-
mance of ADL. In the case of tendon or joint exposure the
hand should be immobilized at all times to prevent
rupture and the splint should only be removed in the pre-
sence of a therapist or a hand expert medical personnel
(70-72). The schedule of splint application varies from
full immobilization, removal for exercises and ADL per-
formance, and later application at night only.
2.
Resting Pan Extension Splint (Palmar)
Severe circumferential bum injuries to the hand mandate
the fabrication of a splint that positions the hand in exten-
sion. The resting pan extension splint (Fig. 36.10) pro-
vides wrist extension, thumb radial abduction, palmar
stretch, MCP joint extension, and interphalangeal joints
extension (3,62,68,73,74). All digits are positioned in
abduction within the splint to prevent syndactyly of the
digits. The range of extension provided should be

498
Functional and Aesthetic Recons truction of Burned Patients
enough to cause blanching of the skin. This splint assists
in prevention of palmar contractures, syndactyly of all
web spaces, and maintains the excursion of the hand
long-flexor musculature. The splint should be altered
with the antideformity burn hand splint at set intervals
throughout the day. A dorsal resting pan extension
splint may be designed to position the hand as described
previously and avoid contact with the painful and sensi-
tive volar hand surface (62) (Fig. 36.11).
Figure 36.9
The bum hand splint positions the wrist in 0-30°
extension, the MCP joints in 70-90° flexion, and IP joints in full
extension. The thumb is positioned in combination of CMC joint
palmar/radial abduction.
3.
Sandwich Splint
When the patient’s hand is positioned in the antideformity
burn hand splint, the interphalangeal joints should be posi-
tioned in neutral (0°). In cases where compliance with this
splint is an issue (i.e. pediatrics) the interphalangeal joints
may flex, which in turn may lead to pressure points on the
fingertips and/or flexion contractures at the PIP joints. A
sandwich splint may be fabricated to prevent this
problem (Fig. 36.12). This splint includes the volar antide-
formity burn hand splint shell and a dorsal thermoplastic
shell, padded with foam and placed over the dorsum of
digits 2-5 extending from the proximal phalanges clearing
the MCP joints to the fingertips of digits 2-5. In cases
where splint migration is an issue, the dorsal component
of the splint may extend to the forearm creating the
effect of a bivalved cast (62,69,75). The dorsal component
of the splint must be padded to prevent pressure points
within the splint (Fig. 36.13). Another way to create the
sandwich effect is to simply fabricate foam dorsal and
volar hand-based shells which sandwich the digits in
extension excluding the thumb (75) (Fig. 36.14).
Figure 36.10
The palmar-based resting pan extension splint provides wrist extension, thumb radial abduction, palmar stretch and
MCP/IP joint extension.

Rehabilitation of the Burned Hand
499
4.
Digital Gutter Splints
When tendon or joint exposure is present as a result of a
deep burn to any of the fingers, a digital gutter splint
may be fabricated to immobilize the affected joints in
extension until re-epithelialization occurs (72,76,77)
(Fig. 36.15). A gutter splint may also be fabricated and
serially adjusted to correct a PIP or DIP joint scar contrac-
ture. Gutter splints can be constructed as a dorsal, volar, or
ulnar digit splint (78-80). A three-point extension splint
may also be fabricated to serially correct PIP flexion
contractures (81). Digital splints immobilize only the
affected joints and allow other fingers to be used in
functional tasks.
Figure 36.11
A dorsal hand-based resting pan extension splint
positions the wrist and digits in extension and avoids contact with
the sometimes painful volar hand surface.
5.
Wrist Splint
In the acute phase of recovery (wound closure/grafting)
when exercise and the performance of ADL is encouraged,
the therapist may consider fabricating a wrist splint in
order to stabilize the wrist and to allow the hand to func-
tion properly. The splint is constructed in cases of contrac-
tures, neurological impairment, and weakness of the wrist
(62,64,68,69,82,83). The design of the wrist splint may
vary depending on wound presence, scar location, pain
or hypersensitivity. It can be designed as a dorsal or
volar splint (Fig. 36.16).
As wound healing continues and scar is formed in a dis-
organized fashion the therapist needs to assess the need for
fabrication of certain specialty splints to counteract the
contractile forces exerted onto the hand. Contracting
scar, if not attended to, may lead to the development of
hand deformities.
Figure 36.12
A sandwich splint may be fabricated to preven t IP join t flexion with in the burn hand splint.

500
Functional and Aes thetic Recons truction of Burned Patients
Figure 36.13
To prevent splint migration, the dorsal component of the sandwich splint may be elongated thus creating a splint with
two shells resembling a bivalved cast.
6.
First Web C-Bar Splint
To prevent first web space syndactyly, a first web C-bar
splint is fabricated to maintain the first web opening and
functionally position the thumb CMC joint for the per-
formance of opposition and grasp-requiring activities
(Fig. 36.17). The splint may be serially adjusted to
increase the first web space (62,68,69,84).
7.
Thumb Spica Anticupping Splint
Cupping of the palm may occur in cases where the hand
has sustained a deep palmar injury (70,85). Scar bands
pull the thenar and hypothenar eminence on the volar
surface of the hand toward each other creating a
“cupping effect” in the hand. The thumb may begin to
hyperextend at the MCP joint, which may lead to further
injury such as joint subluxation or dislocation in severe
cases. A forearm or hand-based thumb spica anticupping
Figure 36.14
A hand sandwich splint may be fabricated uti-
lizing dorsal and volar foam pad components.
splint may be designed to stretch the palm and position
the thumb appropriately for function (Fig. 36.18). A sili-
cone insert may be applied underneath the splint to
soften the scar responsible for causing this deformity.
The splint is serially adjusted until correction is achieved.
8.
Dorsal MCP Block Splint
Severe bum injuries to the dorsum of the hand, if severe,
may cause “palmar planus”, also referred to as flat
palmar arch deformity. As scar causes the hand to contract
dorsally, the arches of the palm flatten making it difficult
for the patient to flex the hand for grasping (70). A
dorsal MCP block splint may be constructed to cup the
hand dorsally and serially block the MCP joints into
Figure 36.15
Digital gutter splints help immobilize digits in
extension and aid in wound healing in cases of tendon/joint
exposure.

Rehabilitation of the Burned Hand
501
Figure 36.16
A dorsal or volar wrist splint may be fabricated
in order to stabilize the wrist and allow the hand to function prop-
erly or to correct wrist flexion contractures.
flexion (Fig. 36.19). This splint places the hand in a more
functional position for grasping. Flattening of the palmar
arches may also occur with a claw hand deformity
during which the dorsal hand skin becomes tight, the
MCP joints hyperextend and the interphalangeal joints
flex (8,86). The antideformity bum hand splint described
earlier in this chapter may be utilized to appropriately
position the claw hand caused by postburn edema.
Figure 36.17
Web space syndactyly of the first web space
may be prevented or corrected with a hard shell (A) of soft
shell C-bar (B) that positions the thumb CMC joint in a functional
position that allows for opposition and grasping activities.
Figure 36.18
A forearm- or hand-based thumb spica that
stretches the palm of the hand and positions the thumb in a func-
tional position may be fabricated to prevent the “cupping” of the
palm deformity.
9.
“Figure 8 ” Swan-Neck Splint
Immature contractile scar anterior to the flexion axis of the
PIP joint can create an imbalance of forces within the
digit’s intrinsic and extrinsic muscles resulting in a
swan-neck deformity. This deformity presents as hyper-
extension of the PIP joint and flexion of the DIP joint
(87-89). A “Figure-8” swan-neck splint or prefabricated
Murphy rings are used to correct mild contractures
(8,64,78) [Fig. 36.20(A, B)]. Serial digital casting is used
for severe contractures prior to application of Figure 8 or
Murphy ring splints. These splints block PIP joint hyper-
extension and allow PIP flexion during the performance
of ADL. They should be worn as prescribed until
healing of the involved structures occurs and the contrac-
tile scars have matured.
10.
Boutonniere Deformity Digital Gutter Splint
Severe dorsal hand bums may cause damage to the exten-
sor mechanism, the extensor tendon, and triangular liga-
ment central slip at the level of the PIP joint. The
resulting Boutonniere deformity presents as flexion of
the PIP joint and hyperextension at the DIP joint
(70,88-90). A digital gutter splint will prevent these con-
tractures prior to their occurrence. Three-point extension
splints or digital casting may also be used for correcting
established contractures. These splints should be worn
continuously and removed only in the presence of a thera-
pist for supervised exercise. If the central slip of the exten-
sor is ruptured, then complete immobilization of the PIP

502
Functional and Aes thetic Recons truction of Burned Patients
Figure 36.19
A dorsal MCP joint block splint may be constructed to cup the hand dorsally and serially correct MCP joint
hyperextension.
joint is prescribed. In cases of tendon rupture complete
immobilization of PIP joint during the wound healing
phase may lead to the production of strong enough scar
resembling a pseudotendon which supports the PIP joint
in extension. The therapist should be careful not to
disturb or destroy this welcome scar (91).
hyperextension contractures (78,92,93) [Fig. 36.21A, B].
A static progressive splint is created by adding a barrel to
a dorsal block splints. The “barrel splint” is used to
correct MCP joint hyperextension contractures of small dif-
ficult to position pediatric hands (94) (Fig. 36.22).
11.
Mallet Deformity Finger Splint
Injury to the extensor tendon over the DIP joint may lead to
the development of a mallet deformity which presents as
finger drop or flexion of the digit at the DIP joint
(8,88,90). If tendon exposure or rupture occurs, the DIP
joint is completely immobilized for up to 6 -8 weeks in:
(A) DIP extension splint gutter volar, and (B) stax splint.
12.
uBarrel Splint”
As discussed earlier in this chapter, full-thickness burn inju-
ries to the dorsum of the hand may later lead to MCP
Figure 36.20
A “figure 8” swan-neck splint (A) or prefabri-
cated Murphy rings (B) are used to correct mild swan-neck
deformities.
Figure 36.21
If tendon exposure occurs, the DIP joint is com-
pletely immobilized for up to 6 -8 weeks in an extension utilizing
a volar gutter (A) or a Stax splint (B).

Rehabilitation of the Burned Hand
503
13.
Thumb CMC Antideformity Splint
The CMC joint may begin to sublux in cases of deep
palmar or dorsal burn injuries when thick immature scar
begin to pull the thenar and hypothenar eminence together.
A hand-based CMC antideformity splint may be con-
structed to stabilize the joint in a functional position and
allow the thumb to correctly oppose during the perform-
ance of ADL (95) (Fig. 36.23).
Figure 36.23
A hand-based CMC splint stabilizes the joint in
a functional position allowing the thumb to correctly oppose
during the performance of ADL.
1.
Hand MCP/IP Flexion Splint
Contracting scars on the dorsal surface of the hand may
affect hand function and lead to joint tightness and hyper-
extension deformities. When tightness of the joints and the
dorsal skin is detected the therapist may prescribe a flexion
splint for the MCP joints (Fig. 36.24) or a composite
MCP/IP joint flexion splint (Fig.
36.25). Elastic
band traction, monofilament line, and finger slings are
attached to a volar forearm based wrist splint to produce
MCP joint flexion. PIP joint flexion may be included
as well by attaching a hook to the fingernails. To
produce PIP flexion, a pulley is created by attaching a
D-ring on the distal aspect of the splint. Monofilament
is attached to the fingernail hook, threaded through the
D-ring and attached proximally with elastic bands.
Another D-ring, acting as a tunnel for the monofilament
lines to go through, is attached on the volar wrist splint
over the proximal palmar crease surface to promote full
DIP joint flexion (78,98). In the absence of fingernails, a
Figure 36.22
The “barrel splint” is used to correct MCP joint
hypertension contractures of small difficult to position pediatric
hands.
B.
Dynamic Splints for the Burned Hand
Dynamic splints are frequently utilized in burn hand reha-
bilitation as an adjunct to remodel scar tissue, stretch a
tight joint, maintain or increase ROM, and provide for
functional hand use during the recovery from a peripheral
nerve injury (96,97). Dynamic splints are usually custom
made by the bum therapist for the special needs of the
patients. However, commercially available prefabricated
splints may be utilized with minor adjustments for
correct fit (62). Positive functional outcomes of dynamic
splinting are increased with proper fit and patient
compliance.
Figure 36.24
A dyn am ic MC P join t flexion splint m ay be
constructed to stretch the contracted dorsal hand skin surface.

504
Functional and Aes thetic Reconstruction of Burned Patients
Figure 36.25
A dynamic composite MCP/PIP joint flexion
promotes maximum excursion of the extensor tendons and
stretches the dorsal hand skin surface.
Figure 36.26
A “fingernail Coban hook” may be constructed
in the absence of fingernail to aid in achieving a composite finger
flexion within a dynamic hand composite flexion splint.
“fingernail coban™ hook” maybe constructed to achieve
composite flexion of the hand. A contoured finger hook
with a coban™ loop is placed over the nail bed (99).
The entire digit is then wrapped with coban securing the
fingernail hook to the digit (Fig. 36.26). Due to the
volarly placed traction, dynamic flexion splints prevent
functional hand use. Dynamic flexion splints are used
periodically throughout the day as prescribed and they
are removed for exercise and ADL.
Frequent inspections and adjustments of the splints are
required to maintain a 90° angle of pull. This angle is
important for the prevention of joint compression, distrac-
tion, and pressure sores caused by uneven weight distri-
bution over the finger slings. Traction provided by the
elastic bands should be between 100 and 300 g and can be
measured with a spring tension scale. A flexion glove may
be used early in the rehabilitation process for exercise pur-
poses to provide hand flexion vs. a composite one (98,100).
2.
Hand MCP/IP Extension Splint
Contracting scar on the volar surface of the hand and
fingers may lead to flexion contractures of the MCP and
interphalangeal joints. To prevent these disabling contrac-
tures, a dorsal forearm based dynamic hand extension
splint is fabricated (98,101). A similar splint is fabricated
when the bum injury to the upper extremity is complicated
with radial nerve injury (78,102). The dynamic MCP
extension splint includes the fabrication of a dorsal wrist
splint extending to just over the metacarpal heads, a
digital extension outrigger, and a thumb MCP extension
outrigger attached to the dorsal splint in such a way to
allow for the correct angle of pull on all digits
(Fig. 36.27). The dynamic traction is provided through
Figure 36.27
A dyn am ic MC P extension splint m ay be constru cted to preven t flexion scar contractures o f the MC P and/ or IP joints.

Rehabilitation of the Burned Hand
505
Figure 36.28
Dynamic traction is provided through finger
slings or fingernail hooks connected to monofilament line and
rubber bands, which in turn connect to a D-ring.
finger slings on the proximal phalanges of all digits. The
slings are connected to monofilament line and rubber
bands which in turn connect to a D-ring on the forearm
surface of the splint (Fig. 36.28). If the flexion contractures
involve the interphalangeal joints then the dorsal splint is
constructed to extend onto the dorsum of the proximal
phalanges just above the head of each proximal phalanx
(103). The dynamic extension hand splints regardless of
their specific intended purpose allow for the functional
use of the hand during the performance of ADL.
Devastating burn injuries to the upper extremities may
require multiple different splints in the rehabilitative
process. Circumferential injuries to the hand would
require both flexion and extension splints which in some
cases become a burden for the patient to carry around.
The “supersplint”, includes a forearm based thermoplastic
shell with volar and dorsal surfaces (104). Flexion and
extension traction is attached, eliminating the requirement
for multiple splints (Fig. 36.29).
3.
Digital Dynamic Flexion/ Extension Splints
Fingers may sustain such severe injury that may require
special attention and individual splinting. Contractures to
the dorsal or volar surface of the digits may be splinted uti-
lizing custom-made or prefabricated spring loaded splints
that correct IP joint contractures (78,101,105). The
dynamic tension provided by the spring mechanism must
be carefully monitored by the therapist and adjusted as
needed to prevent excessive damaging and painful forces
exerted on the digits (Fig. 36.30).
C. Serial Casts
Serial casts provide low-load long-duration stress to tigh-
tened tissues. Brand (106) popularized the idea of treating
leprosy patients with long-standing contractures of the
hand. His method used plaster of paris total contact casts
to produce “tissue growth”. He found cast application
without padding prevented cast migration, provided a
Figure 36.29
The “supersplint” includes a forearm based thermoplastic shell with volar and dorsal surfaces. Flexion and extension
traction is attached thus eliminating the requirement for multiple splints.

506
Functional and Aesthetic Recons truction of Burned Patients
Figure 36.30
Dynamic spring loaded splints may be constructed for individual digits to provide dynamic traction in correcting volar or
dorsal scar contractures.
more intimate fit and thus reduced pressure sores. This
technique has been adapted and used with both plaster of
paris and fiberglass cast tape in burn rehabilitation. Fiber-
glass may be preferred because a less bulky, lighter, and
more durable cast may be fabricated. Clinically, there is
no difference between plaster of paris and fiberglass cast
tape with regard to pressure sore occurrence. Casts are
especially useful in those patients who refuse to or are
unable to comply with removable thermoplastic splints.
Ridgeway et al. (107) reported success with ankle
casting and Bennett et al. (108) have described ROM
increases in several joints with serial casting. Bell-Kotroski
(109) has also presented her experience with digital cylin-
der casting to increase ROM of the PIP joint (109)
(Fig. 36.31). Moreover, plaster and fiberglass cast tape
are less expensive and more accessible than thermoplastic
Figure 36.31
Digital cylinder casts can be applied to individ-
ual fingers to extend tight PIP and DIP joints that are too tight for
conventional thermoplastic or dynamic splinting.
material in many parts of the world. Recently, Deltacast
Polyester conformable Cast Tape™ has become available
and shows great potential in children with burns. This
material can be univalved and used as a total contact
splint (110) (Fig. 36.32). Spellman et al. (111) has reported
success using dynamic traction components incorporated
into plaster of paris casts (Fig. 36.33).
Serial casts are applied when MCP movement is < 3 0 -
45° passively. For patients who do not have sensory defi-
cits, casts are applied and changed the next day. If no
skin complications are noted a cast is reapplied and
changed every 2 -7 days. The insensate hand or finger is
also a candidate for casts. However, one must have
expert technique in application of the device. When con-
sidering application of a cast one must carefully assess
the skin. The presence of small and medium size wounds
are not barriers to using this method; however, they
should be clean and free of infection. The casts of these
Figure 36.32
A splast, made from Delta Cast Polyester Con-
formable Cast Tape™ is univalved and applied to the hand.

Rehabilitation of the Burned Hand
507
Figure 36.33
Plaster of paris cast with dynamic traction for
the fingers.
patients are changed more often (every 1-2 days). Before
applying the cast, wounds should be dressed utilizing anti-
biotic ointments and minimal gauze. Coban® can be
applied for pressure to the scars. Pressure garments
(custom or prefabricated) should be avoided underneath
the casts as they may be damaged or destroyed during
cast removal. ROM measurements should be taken
before the application of any cast to determine treatment
effectiveness.
D.
Skeletal Traction and Sus pens ion
Traction and suspension systems reduce the amount of
contact between the operated on sites and the patient’s
bed thus minimizing the risk of graft loss during dressing
changes (Fig. 36.34). These systems also allow open man-
agement of the grafted wounds postoperatively. ROM can
be performed by changing weights to encourage flexion or
extension of the elbow. Banjo, halo, and hayrake splints
are used in conjunction with elastic bands to suspend
fingers in varying positions. The hayrake provides the
intrinsic plus positioning (Fig. 36.35). A threaded Stein-
man pin is inserted through the distal radius. The pin
must be strong enough not to bend when weight is
applied. There are no reports of damage to either the
median nerve or the radial artery when using this
method (86).
E.
Active Range of Motion
Although splints assist with prevention of contractures,
they alone cannot return patients to a functional and pro-
ductive lifestyle. An exercise program, including active
ROM (AROM), passive ROM (PROM) and prolonged
stretch, in conjunction with splint wear, is the most effi-
cient way to rehabilitate hand burns. Patients are often
hesitant, especially children, to begin movement of the
burned extremity. The hand, with its increased sensory
awareness, is no exception. Patients and families must be
Figure 36.34
Skeletal suspension helps reduce graft loss and
edema in the severely burned hand, and assists with proper posi-
tioning of the upper extremity.
educated about the positive effects of activity as it
relates to strength and bone density. All involved parties
must also be aware of the negative effects of prolonged
immobilization on soft tissue length.
No discussion of exercise can begin without first
addressing the effect of pain associated with thermal
injury. No matter how motivated the burn survivor, ade-
quate pain control is necessary to endure the tremendous
discomfort associated with these injuries in the acute
phase and beyond. Even when pain is diminished, many
adults, and most children also experience problems with
anxiety that prevent them from receiving full benefit
from an exercise program. An interdisciplinary approach,
which includes,
pharmacy,
psychology,
psychiatry,
nursing, and rehabilitation are often helpful in reducing
pain and anxiety (112).
Exercise often begins within the first 24 h after injury.
Initially tightness is caused by edema. Activation of the

508
Functional and Aesthetic Recons truction of Burned Patients
Figure 36.35
A hayrake suspension system provides for
intrinsic-plus positioning of the hand while fragile grafts heal.
This system also allows for passive movement of the fingers
without the need to touch the hand.
muscle pump while the hand is elevated above the heart
will assist in reducing excess fluid (113). Patients should
be encouraged to use as much of their available range as
possible and hold the muscle contraction at end range
for 3-5 s. Often patients are impressed by the improved
range of motion and reduced pain that occurs after
several repetitions of this exercise. Independent perform-
ance of ADL reduces patient frustration with injury and
should be the goal of any exercise program (114). If
splints are required they should be removed before meal
times, exercise should be performed, and independent
feeding encouraged. Utensils and other self-care devices
can be adapted as needed to promote independence
(Fig. 36.36). The success of any exercise program is
judged by improved ADL performance. Few people will
follow through with a boring list of exercises if it does
not increase their functional independence.
Figure 36.36
A universal cuff (A) or a long-handled spoon
(B) are two adaptive devices that are commercially or custom
made to assist with feeding.
The bulky dressings, present in the emergent and acute
phases, decrease the ability to perform fine motor tasks and
prevent the use of many strengthening devices. A series of
different circumference wooden dowels can be placed in
the hand for squeezing exercises (Fig. 36.37). The resist-
ance gives the important proprioceptive feedback necess-
ary to produce strong muscle contractions in the forearm
(115). Strong muscles are necessary to overcome the con-
tractile forces, which will be present in the maturation
phase of scar healing. As wounds heal and dressings
decrease, a greater variety of functional and strengthening
activities become available.
Areas requiring skin grafts can continue strengthening
during the immobilization phase with isometric exercise.
Of course, this is not possible in smaller children or
adults who do not possess the cognitive ability to under-
stand and perform this method of strength training.
Shear forces produced when isometric contractions result
in significant joint movement lead to graft mortality.

Rehabilitation of the Burned Hand
509
Figure 36.37
Wooden dowels are inexpensive exercise equipment that can be used several times a day for resistance exercise.
Any therapist who knowingly allows graft loss to occur
will quickly lose the confidence of the physician who
painstakingly performed the operation. Active motion
and strengthening can be resumed once graft adherence
occurs; usually between 4 and 7 days postoperatively.
Sanford and Gore (116) have reported a 95% graft take
on skin grafts when using an Unna boot after grafting
the hands as an outpatient procedure (116). The Unna
boot is removed on the fifth postoperative day and rehabi-
litation begins.
F.
Pas s ive Range of Motion
PROM is beneficial when working with infants, young
children, and patients who are unable to cooperate with
an active rehabilitation program, such as adults with cog-
nitive impairments. In the acute phase, bums covering
large amounts of the body may prevent patients from par-
ticipating in an effective AROM program. During this time
PROM will maintain range of motion, joint elasticity, and
provide nutrition to the joint surfaces (114,117,118).
Passive motion does not increase muscle strength or
decrease edema and should not be used in patients who
are able to participate in an active movement program.
Covy et al. (119) found continuous passive motion
machines, provided results similar to an aggressive
active and passive range of motion program. No graft
loss occurred when machines were applied to the hand
on postoperative day 5. Covey et al. suggest these
machines be used when multiple kinetic areas are
involved, for patients with decreased cognitive function
who cannot participate in AROM, or for patients who
refuse and are unwilling to participate in an AROM
program.
G.
Prolonged Stretch
Prolonged stretch, although a passive movement, does
have an important role in treatment of the burned hand.
As scars hypertrophy due to an increased and altered extra-
cellular matrix the skin tightens and ROM limitations are
noticed (120). Patients who are experiencing limitations in
AROM can be moderately stretched for several minutes up
to 30 min. To ensure sufficient stretch, mild skin blanching
should occur (121). These long-duration stretches provide
sufficient time to break the bonds of excess collagen and
lengthen skin and other soft tissues. Scar bands that
cross more than one joint are stretched concurrently
(122). Heat modalities such as hot packs or fluidotherapy
are helpful prior to stretching. Combining heat and
stretch has been shown to be especially effective
(61,123). The hand can be wrapped in a Coban™ fist
and dipped in paraffin, or covered with a hot pack
(Fig. 36.38). Finally, dynamic and static progressive
Figure 36.38
Cob a n ™ fist with paraffin.

510
Functional and Aesthetic Recons truction of Burned Patients
splints, and serial casts are other ways to provide low-load
long-duration stretch. Fingers with limited PIP and DIP
ROM due to skin and joint contracture can be progress-
ively stretched using Theraband®, or Coban® (124). Pro-
longed stretch has been shown to improve ROM in a
variety of contractures (125-127). Clinically, the same
results have been observed in burn scar contractures of
the hand.
Patients often learn substitution patterns to compensate
for ROM limitations. Therefore, it is important to include
functional and strengthening activities after every stretch-
ing session to integrate newly gained range into the
patient’s movement patterns (128). Functional exercises
should focus on basic ADL initially and progress to simu-
lated work situations later. Prolonged stretch can easily be
taught to patients and family members and included in the
daily home exercise program.
H.
Jo int Mobilization and Tendon Gliding
Although the skin of burn survivors is the most obvious
source of ROM limitations; several other soft tissues
may contribute to tightness after prolonged periods of
immobilization or in the presence of well-developed con-
tractures. Collateral ligaments and other periarticular
structures at the PIP and DIP joints tighten with extension
splinting due to the increase in cross-linking between adja-
cent collagen fibers (129). The MCP joint is splinted in
flexion
to
prevent
collateral
ligament
tightness.
However, noncompliance or severe scarring over the
dorsum of the palm can cause hyperextension contractures
at this joint. When this deformity occurs, collateral liga-
ments tighten along with the posterior joint capsule and
lumbrical and interossei muscles.
Joint mobilization and joint distraction, designed to
lengthen the tightened joint capsule and ligaments are
helpful in increasing ROM. Heat modalities can also be
implemented to aid in stretching tightened articular
tissue (130). At the PIP joint, tight collateral ligaments
and oblique retinacular ligaments will also prevent joint
flexion. A simple dynamic splint is effective in stretching
this joint. Tendon gliding exercises are also useful when
trying to gain ROM and prevent peritendinous scar
adhesion (131).
I.
Scar Manage me nt of the Burne d Hand
The desired outcome of any wound as it closes is a flat,
soft, and elastic scar. As deep partial- or full-thickness
burn hand injuries heal, hypertrophic contractile scars
may begin to form —8 weeks after wound closure
(132,133). Red, raised, and rigid hypertrophic scars are
the result of an overabundance of collagen fibers gathered
at the injury site to aid in wound healing (134). The
collagen synthesis at the wound exceeds the amount of
collagen breakdown (lysis) resulting in a thick nonyielding
scar (70,134). Researchers have noted that areas which
have undergone skin grafting tend to form less hyper-
trophic scars than those that have been allowed to heal pri-
marily. Also, scar hypertrophy has been noted to be more
prominent at the borders of the grafted areas and the
normal skin (134,135). Hand scar management should be
initiated early to prevent skin contractures and soft tissue
adhesions, which may significantly impair function. Prior
to treating hypertrophic scars in the hand the therapist
should carefully assess their maturation status and how
they may affect function. Their location should be
recorded in order to track their progress and the success
of therapeutic interventions. Several instruments are avail-
able to aid in the assessment of hypertrophic scars
(134,136,137).
The therapeutic management of hypertrophic scars con-
tinues to be a challenge to the therapists. Even though
explaining the process of scar maturation continues to be
the focus of researchers, burn hypertrophic scars have
been managed clinically through pressure therapy,
massage, stretching, and physical agent modalities
initiated at different stages in the recovery process (138).
1.
Pressure Therapy
Pressure exerted on hypertrophic scars may be applied in
the form of interim or custom garments, inserts, and con-
forming orthotics.
Pressure Garments
Clinically, pressure garment therapy has been the stan-
dard of care for the treatment of hypertrophic scars.
However, the efficacy of pressure garments and the
amount of pressure needed for therapeutic effect has not
yet been objectively demonstrated (139-142).
It has been thought that pressure decreases blood flow
to the scar, which, in turn, decreases oxygen within
tissues. This decrease results in a balance of collagen syn-
thesis and breakdown (lysis) within scars. Balancing col-
lagen synthesis with breakdown is believed to flatten
scar tissue (70,86,135). Pressure therapy in the hands
may begin before complete wound closure. Low pressures
o f-1 0 mmHg may have a positive effect on the remodel-
ing of a scar over time. Continuous pressures >40 mmHg
may cause paresthesias and damage tissues (86,133).
Average pressure of 25-28 mmHg has been the most
accepted by researchers, therapists, and companies fabri-
cating custom pressure garments (134). Self-adherent
elastic bandages such as Coban™ may be used initially
to control edema and later on to provide pressure to skin
grafts postoperatively as well as manage sensitive hyper-
trophic scars (50). A Coban™ glove although exerting

Rehabilitation of the Burned Hand
511
Figure 36.39
Interim hand pressure therapy may include
commercially available products such as Isotoner™, spandex,
or cotton gloves and finger sleeves.
—lOmmHg pressure when not stretched, may be thera-
peutic over time (86,134). Application of Coban™
gloves does not interfere with wound dressings and elim-
inates shearing forces on fragile skin. The Coban™ is
applied in a spiral fashion on each digit beginning distally
at the fingernail and ending proximally at the head of the
MCP joint. The fingertip is exposed to monitor capillary
refill. When the Coban™ is applied spirally it should
overlap half its width in order to provide equal pressure
throughout the finger. When stretched beyond 25% of its
elasticity, Coban™ can cause numbness to the fingers.
When the Coban™ hand glove is completed, all surfaces
of the hand should be covered and no skin should be
exposed with composite finger flexion. A small amount
of lotion may be applied to the glove to prevent the
fingers from sticking together and allow the hand to be
used functionally (86). Other forms of interim hand
pressure include commercially available products such
as Isotoner™, spandex, or cotton gloves and finger
sleeves (70,86) (Fig. 36.39). Interim pressure is introduced
first as a form of circumferential pressure to prepare the
hand for the next level of care. Once edema subsides
and hand sensitivity decreases a custom-made glove is fab-
ricated (Fig. 36.40). The therapist may choose to prescribe
a glove with a zipper initially for easy application in pre-
venting excess shearing forces onto the fragile scar. Later,
the zipper is discontinued in order to achieve more
uniform pressure onto the entire hand surface. Open fin-
gertips should be required in order to provide the patient
with the sensory feedback needed to perform ADLs.
Pressure gloves should be worn around the clock and
removed only for bathing, exercise or wound care.
Custom gloves should be monitored closely for good fit
and should be replaced every 8-12 weeks depending on
wear and tear or growth in the case of children. In cases
of deformities in the hand or partial amputation, a positive
mold of the hand may be obtained and sent to the garment
manufacturer for a custom glove fabrication (143).
Inserts
Because of its unique anatomy and function the hand
has very different dorsal and volar surfaces. Palmar
arches and the thenar and hypothenar eminence create a
concave volar surface which is difficult to manage with
pressure garments alone. Also, adequate pressure in the
web spaces may be impossible to achieve just with a
glove. For these difficult-to-manage surfaces, inserts are
used underneath gloves to achieve adequate pressures
(86,134,144). Inserts are fabricated from materials avail-
able commercially and provide total contact pressure on
uneven surfaces. A wide variety of these materials
Figure 36.40
Once edema subsides and hand sensitivity decreases, a custom-made glove is fabricated.

512
Functional and Aes thetic Reconstruction of Burned Patients
the hand (Fig. 36.42). This soft, flexible, and expandable
insert permits hand flexion for the performance of ADL
while providing pressure in the palm of the hand
(86,144,146).
Silicone gels: Although the exact mechanism of how
silicone affects the bum scar is not well defined, silicone
gels appear to be the most widely utilized insert materials
in burn rehabilitation (147,148). Because of their flexi-
bility and conformity they may be used on all hand sur-
faces (Fig. 36.43). Today, silicone gels are available in
different sizes and may have one sticky surface which is
applied on the scar to avoid insert migration from the treat-
ment surface. These gels even though they are expensive
and short-lived, have been clinically observed to depress
scar hypertrophy and hydrate the scar thus making it
more pliable and yielding (86,144,146).
Silicone elastomer: Liquid elastomer mixed with a cat-
alyst makes a solid yet soft insert for the dorsal or volar
surfaces of the hand and its web spaces (Fig. 36.44). Sili-
cone elastomer inserts because of their initial liquid stage
include foams, silicone gels, silicone elastomers, silastic
pads, putties mixed with silicone catalysts, and hard ther-
moplastic materials. When selecting an insert to be utilized
inside the pressure providing glove, the therapist should
take into account the stage of the scar maturation. To
prevent skin breakdown, initially soft inserts should be uti-
lized. As scars mature, firmer materials can be introduced.
Also, it is important to consider the location of the insert
application prior to choosing the insert material. Soft, flex-
ible inserts that allow for movement to occur should be
used in the palmar surfaces (86).
Soft material inserts: Initially in scar management soft
strapping or foam padding material web inserts may be
fabricated to prevent or correct syndactyly (144,145)
[Fig. 36.41 (A, B)]. Roylan® prosthetic foam inserts may
be fabricated to fill the concavity on the volar surface of
Figure 36.42
Roly an® prosthetic foam inserts may be fabri-
cated to fill the concavity on the volar surface of the hand.
Figure 36.44
Silicone elastomer inserts are custom made to
conform greatly to all hand surfaces especially the web spaces.
Figure 36.41
(A, B) Initially, in scar management, soft strap-
ping or foam padding material web inserts may be fabricated to
prevent or correct syndactyly.
Figure 36.43
Silicone gel inserts are flexible, soft and
conform to all hand surfaces.

Rehabilitation of the Burned Hand
513
conform greatly to any anatomical surface and are clini-
cally observed to prevent shrinkage of newly applied
skin grafts (86,144,146).
Otoform K™: Several silicone-based putties such as
Otoform K™ when mixed with a catalyst result in a semi-
rigid insert material which may be utilized in areas such as
the dorsum of the hand and the web spaces in the latter
stages of scar management when the scars in the hand
are not as fragile (86,144) (Fig. 36.45).
Roylan® 50/50 Mix™ elastomer putty: This technol-
ogy involves mixing two equal size putties to form a semi-
rigid insert. Like Otoform K™, this is best used on the
dorsum of the hand and web space surfaces in the later
stages of scar management (146).
Hard thermoplastic inserts: Conforming splints utilized
alone or lined with silicone or other materials may provide
adequate pressure needed to depress hypertrophic scars
(138). All insert materials must be cleaned frequently
and the treated areas must be inspected regularly in
order to prevent skin breakdown, scar maceration, or der-
matitis. Treatment must be discontinued temporarily when
skin irritation occurs. Patients may be allergic to certain
Figure 36.45
Silicone-based putties such as Otoform K™
when mixed with a catalyst result in a semi-rigid insert material,
which may be used on the dorsum of the hand or the web spaces
during the latter stages of scar management.
insert materials, so in some cases trial and error will
show which insert material is best for the patient.
J.
Phys ical Agent Modalities Utilized
in Burn Hand Scar Managem ent
Thermal and nonthermal physical agent modalities have
been widely utilized as an adjunct to rehabilitation. Even
though these modalities are frequently used for a variety
of diagnoses, their use in bum rehabilitation remains
limited.
Prior to choosing the appropriate modality to manage
the burned hand, the hand’s unique anatomy must be con-
sidered. The structures of the hand are mostly superficial
and may respond well to heat that penetrates 1-2 cm
beneath the skin. Also, dermal thickness varies from its
volar to the dorsal surfaces which allows for structures
to be heated at different temperatures (149). A good exam-
ination of hand sensation should precede initiation of heat
modalities in order to verify the presence of at least protec-
tive sensation to prevent further injury to the already com-
promised hand.
Paraffin wax: One of the most frequently utilized mod-
alities in bum hand management may be paraffin (150).
When mixed with mineral oil the temperature of paraffin
is lowered to therapeutic levels of 115°F and may heat
tissues up to 2 cm subcutaneously via conduction (151).
The patient’s hand may be stretched into flexion with
Coban prior to receiving paraffin. The methods of immer-
sion of dipping of the hand may be utilized after one layer
of paraffin wax has covered the hand and has solidified. In
the case of a hypersensitive hand paraffin wax may be
painted onto the hand or poured in saran wrap creating a
paraffin pack which is then wrapped around the hand.
Once paraffin is applied to the hand, saran wrap and a
towel are applied around it for insulating purposes. This
maintains
therapeutic
heat
levels
for
12-15 min
(114,122,151). The application of paraffin wax on a
stretched hand may increase collagen extensibility, may
improve skin elasticity, and may increase movement in
the hand (152).
Ultrasound: Experimentally, ultrasound has been utL
lized in burn hand rehabilitation during the wound
healing phase and for the management of hypertrophic
scars and contractures. Despite several attempts to objec-
tively demonstrate the effects of ultrasound on burn
scars thus far studies have been inconclusive and contra-
dictory (70). Theoretically, the benefits of ultrasound are
increased circulation, acceleration of wound healing, soft-
ening of collagen, increased scar plasticity, decreased
pain and muscle spasm, and change in contractile activity
of muscles. Clinically, 1 MHz continuous ultrasound at
1.0 W/cm2 intensity, performed three times weekly onto
an approximate 4 x 4 cm2 surface for 5 min may

514
Functional and Aesthetic Recons truction of Burned Patients
positively affect scar extensibility and increase joint mobi-
lity (153).
Fluidotherapy: The use of this modality may be contra-
indicated in managing the burn hand acutely as this is a
skin-drying physical agent which may further damage
the moisture deficient injured skin. It may be utilized
later in the rehabilitative phase of recovery when mana-
ging the stiff hand with an intact skin surface resulting
from an electrical injury to the upper extremity. This con-
vection heat modality allows the therapist and the patient
to manipulate the hand while heated in the fluidotherapy
machine, thus combining the effects of heat, stretching,
and movement.
Other modalities may include hot packs which are in
some cases combined with paraffin wax to provide super-
ficial moist heat. Electrical stimulation has been infre-
quently utilized in burn hand management, however, its
efficacy is unsubstantiated (70).
K.
Scar Mas sage
Currently, no objective study clearly and objectively
demonstrates how massage may affect hypertrophic burn
scars. Limited studies suggest that massage does not
affect the vascularity, pliability, and height of burn scars
(154). Other studies revealed positive psychological
effects of massage therapy for the burned patient related
to itching, anxiety, and pain (155,156). Clinically,
massage is widely utilized by therapists in managing
bum scars (150). Massage may soften or remodel adherent
scar tissues by reversing fibrosis, improve blood circula-
tion, and increase joint mobility prior to therapy. Retro-
grade (pumping) massage should be performed prior to
scar massage in order to move any excess fluids away
from the hand. Initially, massage may begin as early as
1-2 weeks after wound closure. However, when the scar
is still fragile, massage must be performed in a stationary
fashion. The therapist performs a nonfriction massage
technique by applying gentle stationary pressure on the
hand surface treated and mobilizing the blanched skin
surface in all directions without friction. No lubrication
should be used during this scar massage technique. As
the scar continues to mature and is able to withstand
shear forces, frictional massage may be introduced. Lubri-
cation may now be used; however, it should not be exces-
sive and movements should be performed slowly in a
horizontal, vertical, or circular fashion. If a wound is
present, massage and stretching of the scar tissue should
be directed toward the wound periphery. This relaxes the
surrounding tissues and promotes wound healing. The
hand scar tissue may respond better to massage when it
is heated and stretched. In addition to manual massage
the therapist may provide electrical massage to all hand
surfaces
including
the
web
spaces.
Commercially
available electrical massagers with various attachments
may be utilized in the clinic or issued to trained patients
and their families for home scar management (157).
Home massage should be performed at least twice daily
for 5-10 min on each treated hand surface. The therapist
should frequently inspect the skin integrity to prevent
“over massaging” an area and causing skin breakdown
or blistering.
V.
CAPSULOTOMY
Despite expert hand therapy, contractures of the hand can
involve more than tightened skin tissue. Joint capsules and
periarticular structures may also be involved and continue
to limit ROM after bum scar releases (158). Intraoperative
range of motion measurements should be taken of MCP
and interphalanged joints. If ROM is not adequate after
burn scar release a capsulotomy should be considered.
Rehabilitation should include a pre- and postoperative
evaluation which must include AROM, PROM, as well
as skin integrity, functional level, and pain tolerance.
The preoperative evaluation should also include a strength
assessment (159). It is generally accepted that AROM
begin within 24-36 h postoperatively (159). However, in
the case of a burn scar release and placement of autograft
hand therapy must be postponed until grafts are adherent.
The therapist’s goal during this first phase of treatment is
to control edema and maintain proper positioning of joints
that have been released.
Once the physician allows ROM to begin the patient
must be taught to perform AROM exercises on an hourly
basis. Patients must understand that in order to prevent
future limitations from scarred skin and joint capsule exer-
cises must be performed religiously. Clinically, splints are
helpful in maintaining ROM whenever the patient is not
exercising (159). Dynamic splints are helpful in gaining
full ROM. Varying heat and prolonged stretch modalities
described earlier in this chapter can also be employed if
necessary. Strengthening activities begin after edema and
pain subside. Limited information has been published on
rehabilitation after capsulotomy. However, Gould et al.
(160) report between 20° and 30° increases in AROM at
the MCP joint (160). Buch (161) also reports an average
increase of 30° improvement at the MCP joint, but states
that results were significantly less when skin grafts were
performed at the same time as capsulotomy (161).
Therapists must use their best clinical judgment when
developing a specific treatment plan for the management
of these very complex patients. Generally, ROM should
begin as soon as possible and basic principles of edema
management, prolonged stretch and strengthening should
be used.

Rehabilitation of the Burned Hand
515
VI.
AMPUTATIONS
Amputations of the fingers occur often in severe burns.
However, patients who have mid-proximal phalanx con-
tractures can do quite well with ADLs. It is important
with these patients not to lose further length to hyper-
trophic scar tissue. Care must be taken to maintain the
fingers separated at all time to prevent a mitten hand. It
is also important to maintain the intrinsic plus position.
This is difficult because decreased finger length reduces
the lever arm, thereby decreasing splint efficiency.
Pinning of the MCP joints in flexion should be considered
if splints cannot maintain the desired position. Aesthetic
prostheses are available for persons who have lost portions
of fingers. These are very realistic but are, for the most
part, nonfunctional and expensive.
Prosthetics come in many styles. A consultation with a
local prosthetist should be obtained as soon as possible fol-
lowing amputation. The rehabilitation therapist should
strengthen the residual limb. Especially the muscles of
the shoulder girdle. Most mechanical prostheses require
strong shoulder protraction, retraction, and elbow flexion
to operate effectively.
VII. SUMMARY
Rehabilitation management of the burned hand can be an
overwhelming task, especially in association with other
severely injured areas of the body. A team approach,
including the physician, nurse, rehabilitation therapist,
and family is absolutely necessary for successful out-
comes. The physician and therapist must have a compre-
hensive
understanding
of
hand
anatomy,
edema
prevention, scar formation and maturation, splinting, and
the power of low-load long-duration stretch in order to effi-
ciently manage hand bums. Armed with this knowledge,
an appropriate treatment plan can be developed to return
the patient to a more independent level of function.
Nursing staff must be educated to reinforce rehabilitation
goals. Most importantly, the family and patient must be
involved in and understand the goals of treatment.
Without compliance from the patient and support from
their loved ones, hand function will certainly be
compromised.
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37
Recons truction of Burn Deformities of the Lower Extremity
ROBERT L. McCAULEY
University of Texas Me dical Branch and Shriners Hospital for Children— Galveston Unit, Galveston, Texas, USA
MALACHY E. ASUKU
Ahm adu Bello University Teaching Hospital, Kaduna, Nigeria
I.
OVERALL VIEW OF ACUTE CARE IN
LOWER EXTREMITY BURNS: CONCERNS
A. Introduction
According to the Wallace rule of nine, the lower extremi-
ties constitute 36% of the total body surface area (TBSA).
Using the Lund and Browder charts, this area of the body
is 45% in adults and 39% in children (1). Bum injuries to
the lower extremities can, therefore, be a major concern
either as a result of large TBSA involvement or due to
compromise of specialized anatomic and functional units
such as the foot (2,3). The American Bum Association,
in recognizing the functional importance of the foot, has
designated its involvement in bum injury as a major
burn requiring inpatient treatment for optimal outcome
(2-5). Lower extremities bum injuries, whether occurring
in isolation or as part of a more extensive surface area
injury can, therefore, significantly affect the overall reha-
bilitation of the patient (2-6).
B.
Special Cons iderations in Acute Care
Bums to the lower extremities can result from a variety of
agents occurring usually under accidental circumstances
(2,3). While scald injuries and flame bums often result
in superficial and deep partial-thickness bums, contact
burns and high-voltage electrical bums will often result
in either full-thickness burns or fourth degree bums (5).
Less common causes such as chemicals may also
produce serious burns to the lower extremities (5). Aside
from the depth of the burns, regional characteristics tend
to impact on the severity of lower extremity burn injuries
521
I.
Overall View of Acute Care in
B.
Late Reconstruction
529
Lower Extremity Burns: Concerns
521
1- Inadequate Soft Tissue
A.
Introduction
521
Coverage (Unstable
B.
Special Considerations in Acute Care
521
Scars and Chronic Ulcers)
529
II.
Reconstruction of the Burned
^
Burn Scar Contractures
531
Lower Extremity
523
3* Amputations
538
A.
Early Reconstruction
524
4- Recent Advances
539
1.
Acute Wound Coverage 524
References
542
2.
Early-Onset Functional Impairment
528

522
Functional and Aes thetic Recons truction of Burned Patients
(1-6). First, the edema associated with deep partial- and
full-thickness bum injury to the lower extremity is made
worse by dependency. Walking, standing, or even sitting
with the lower limbs in dependent position without
elastic support (such as ace wraps, compression garments,
etc.) can lead to increase in hydrostatic pressure resulting
in edema in the severely burned limb (1). Edema can
enhance inflammation, resulting in pain and a decrease
in mobility of the injured parts. These circumstances
may result in joint stiffness, which may impair subsequent
rehabilitation. In the acute phase of injury, control of
edema is best accomplished by elevation of the affected
part of the lower extremity in bed. However, one must
be cognizant of the attendant dangers of immobilization
and hospitalization for such injuries. The goal of manage-
ment is, therefore, to facilitate early ambulation with sup-
portive stockings (1,5,6).
Second, circumferential injuries resulting in edema in
lower extremity bums can lead to the development of com-
partment syndrome. Elderly patients who may also have
antecedent peripheral vascular insufficiency and patients
suffering high-voltage electrical injuries are reported to
be at increased risk in this regard (1-3). A high index of
suspicion is required to embark on a timely evaluation of
the neurovascular status of the affected limb in order to
determine the need for immediate decompression (1-3).
It is important to appreciate the fact that while peroneal
nerve palsy may be due to direct injury to the common
peroneal nerve at the neck of the fibular, where it runs a
relatively superficial course, it may also result from an
imminent compartment syndrome. Mani and Charte (1)
observed that escharotomies and fasciotomies when indi-
cated should be done early in the resuscitative phase
before tissue perfusion is compromised. Although the
decision to decompress is often based on clinical features,
effective tissue perfusion essentially stops when tissue
pressure reaches 40 mmHg (1). While escharotomies
can be done at the bedside, fasciotomies require more
elaborate preparation for anesthesia and occasionally
blood replacement.
The involvement of the lower extremity in high-voltage
electrical injuries, however, generates other concerns.
The bulky muscles of the thigh may suffer myonecrosis
releasing large volumes of breakdown products that may
constitute a significant threat to renal function and to the
patient (1). The level of threat, however, can be signifi-
cantly minimized with diligent fluid therapy and timely
debridement of nonviable muscle tissue. These patients
may eventually require early soft tissue reconstruction in
order to close their wounds.
In the past, the technique of wound excision for deep
partial- and full-thickness burns was a subject of debate.
Surgeons were divided between tangential excisions and
fascial excisions (1,6). Proponents of fascial excision
argued that such excisions guaranteed complete excision
of nonviable tissue and that it is technically easier to
perform, and accompanied by lesser requirement for
blood transfusions. On the other hand, the proponents of
tangential excisions believed that the subcutaneous tissue
should be preserved since it has an important role in pre-
venting adhesion of skin grafts to fascia, which is import-
ant in the growing child. Furthermore, they observed that
the outcome of tangential excision is aesthetically superior
to that of fascial excision. However, currently, fascial
excisions in the lower extremity have been largely aban-
doned due to the associated long-term contour deformities
as a result of chronic edema, lymphedema, and muscle
atrophy (6). Initial concerns over excessive blood loss in
tangential excisions are now addressed by meticulous
efforts at hemostasis. These include the use of hypotensive
anesthesia, the application of tourniquets, the elevation
of the limb during surgery, and the use of thrombin and
epinephrine on the wound surface (1).
Another problem encountered in lower extremity burns
is the paucity of soft tissues over such areas as the tibial
tuberosity, the shin, the malleoli, and the toes. These
areas are, therefore, more predisposed to deep burns with
exposure of tendons, bones, and joints. This is particularly
true following electrical burns (2,3). Consequently, these
areas may heal in a delayed fashion since they are
devoid of the freely mobile soft tissue padding required
for any degree of wound contraction to occur. Such
areas may require flap coverage in order to obtain satisfac-
tory long-term results.
Fears have been entertained that lower extremity burn
wounds may be at increased risk of wound infection
with the perineum as a potential source of contamination.
This has led to the preference of irrigation of the burned
area rather than the immersion that is done during
tubbing in some centers (1). Although this fear has
remained unsubstantiated, meticulous wound care and
appropriate bacterial monitoring as well as the judicious
use of topical and systemic antimicrobials should
prevent the conversion of partial-thickness wounds to
deeper injuries. Superficial partial-thickness burns are,
therefore, expected to heal with excellent functional and
aesthetic results within 2 weeks (1). On the other hand,
deep partial- and full-thickness burns invariably require
resurfacing with skin grafts or flaps. Unexpanded sheet
grafts are preferred to mesh grafts in resurfacing the
lower extremities. However, such an approach is subject
to autograft availability since higher priority areas such
as the face and hands usually take precedence (2,3).
Traditionally, the lower extremity constitutes the most
frequently harvested donor site for autogenous skin
grafts. The large and uniform surfaces provided by the
thigh make it most suitable as a donor site. Therefore,
when the thigh is involved in deep partial- or full-thickness

Reconstruction of Burn Deformities
523
burns, one is not only faced with the problem of covering a
large surface but also with the possibility of loss of a
quality skin graft donor site. This places a high premium
on available donor sites particularly when the injury is
part of a large surface area burn. Under such circum-
stances, other less suitable donor sites such as the back,
the buttocks, and the abdomen may have to be utilized
and recropping may become necessary. The use of syn-
thetic skin substitutes, cultured autografts, and allografts
in burn wound coverage must be seen as attempts at
providing more options rather than as alternatives for
autogenous skin grafts (1).
Commencement of ambulation following the appli-
cation of skin grafts to the lower extremity has also been
attended by divergent opinions (7-12). However, early
ambulation as soon as the grafts have “taken” securely
should be the gold standard (6). The grafted lower extre-
mity may require a custom-fitted compression garment
and the use of elastic wraps during ambulation to minimize
the effect of hydrostatic pressure and edema formation.
The use of the Unna Boot® (Dome-Paste Bandage, Mile
Inc., West haven, CT) has been acclaimed to solve the
problems of blistering and graft separation previously
encountered with early ambulation (6,13,14).
Burns of the weight-bearing surface of the foot may be
deep enough to require resurfacing despite the limited
exposure of the area and the protection provided by the
thickened epithelium and the use of footwear. Such deep
injuries are commonly encountered as exit wounds in elec-
trical bums or arise from prolonged contact burns in
patients with peripheral neuropathies (2,3,6,15,16). The
main concern here is over the prospect of obtaining
durable coverage. Destruction of the plantar fascia may
disrupt the intrinsic mechanism of arch support and
mandate long-term orthotic inserts (2,3). There are varied
opinions as to the most suitable means of resurfacing
the weight-bearing surface of the foot. Split- and full-
thickness skin grafts as well as pedicled flaps have all
had their moments of glory with each falling short of pro-
viding the highly specialized characteristics of the normal
plantar skin (16-20). Kucan and co-workers (2,3) noted
that a combination of flexibility and durability is required
of any tissue used to resurface the sole of the foot and this
must be accomplished without excessive tissue bulk that
will hinder the use of footwear. The requirement for
ideal plantar resurfacing is therefore a durable tissue of
moderate volume that will affix tightly to deeper structures
resisting shear forces and is capable of attaining protective
sensation. This group further observed that split-thickness
skin grafts are no less durable than full-thickness skin
grafts. Consequently, split-thickness skin grafts continue
to be the primary method of coverage for the plantar
surface as long as there is adequate supporting sub-
cutaneous tissue.
Another early concern following deep burns of the foot is
the tendency to develop shortening of the Archilles tendon
(6). Prompt and proper use of splints and casts may be
required to maintain the ankle joint in a plantar-grade pos-
ition while the proper use of footboard may suffice in the
nonambulatory patient. However, vigilance and good care
of pressure points are required to prevent the development
of pressure sores with the use of these appliances (6). The
importance of maintaining joint motions particularly in
the multijointed ankle and foot in the immediate post
injury period cannot be overemphasized. The biomechanics
at these joints are highly complex with motions occurring
simultaneously in a number of planes during both the
weight-bearing and non-weight-bearing phases (2,3).
Success at rehabilitation of the burned lower extremity
will, therefore, depend on maintaining these joint functions
rather than correcting any ensuing deformities.
Finally, the issue of inpatient versus outpatient manage-
ment of lower extremity burns is one that is frequently
debated. Zachary et al. (5) noted that isolated burns of
the feet has the distinction of being the most common
bum injury to be initially treated on outpatient basis.
Yet, many of these patients subsequently require hospital-
ization due to significant morbidity. They, therefore,
suggested that patients with this injury are better served
by inpatient care. Lyle et al. (15), in emphasizing the
same view, identified cellulitis, hypertrophied scarring,
and prolonged hospitalization as possible complications
of initial outpatient care of the burned foot (15).
Although the depth of the injury is key to determining
the complexity of treatment, effort required in the acute
care of the burned lower extremity, control of edema,
early tangential excision and resurfacing with skin
grafts, appropriate splinting, and early ambulation are
fundamental to a successful outcome.
II.
RECONSTRUCTION OF THE BURNED
LOWER EXTREMITY
Though adequate care in the acute phase of lower extre-
mity burn injuries can significantly minimize the need
for reconstructive procedures in later years, less than
optimal outcome may occur as a consequence of deep
initial injuries. The effects of weight bearing and ambu-
lation as well as growth in patients who have suffered
early childhood burns may also contribute to the develop-
ment of deformities. Varying complexity of reconstructive
efforts is, therefore, required in order to obtain the
maximum functional potential of the thermally injured
or deformed lower extremity. Brou et al. (21) noted that
in a survey of 25 patients who survived a mean TBS A
bums of 71% (65% full thickness), 27% (136/512) of
the total reconstructive needs were in the torso and

524
Functional and Aesthetic Recons truction of Burned Patients
lower extremities. The principal reconstructive goals for
the lower extremity are weight-bearing and unimpeded
ambulation. Achieving these goals require the provision
of stable and durable skin coverage accompanied by pro-
tective sensation and proprioception. The final outcome
should not only permit proper shoe fit but also play a
role in boosting self-esteem (2,3).
Experience has shown that a sure way to achieving
optimal outcome in the reconstruction of the burned
patient is through integrated team approach with realistic
goals set to meet the individual’s needs. According to
Kucan and co-workers (2,3) reconstruction of the burned
lower extremity may be divided into two phases: (1)
early: beginning at admission and extending up to 1 year
after injury; and (2) late: commencing after 1 year of
injury. In the early phase, reconstructive procedures may
be required in the closure of complex wounds as well as
in the prevention and correction of early onset functional
impairments. The late phase, however, contends with pro-
blems of chronic instability of soft tissue coverage, burn
scar contractures, contour deformities, growth disturb-
ances in children, and revision of amputation stumps.
A. Early Recons truction
7.
Acute Wound Coverage
Reconstruction for acute wound coverage may be indi-
cated in deep partial-, full-thickness and fourth degree
bums in which exposure of underlying structures may
present significant wound coverage problems (2,3).
These injuries commonly result from high-voltage electri-
cal bums and contact bums typified by the muffler bums
commonly seen in motorcycle accidents. Extensive soft
tissue losses with exposure of tendons, ligaments, neuro-
vascular trunks, bones, and joint spaces characterize
these injuries. Kucan et al. (2,3) observed that skin grafts
are inadequate to achieve either short- or long-term recon-
structive goals in these injuries. Invariably, composite
tissues in the form of flaps are required for closure of
such wounds and options will depend to a large extent
on the anatomical location of the wound or defect.
The Thigh
The wide circumference of the thigh as well as the
abundance of soft tissues allow for excision and primary
closure of limited deep bum wounds. When soft tissue
loss is extensive, however, the first option lies in the use
of adjacent soft tissues as advancement or transpositional
flaps to fill up the defect and achieve closure. The nature
as well as the location of the defect and recipient bed con-
tributes to determining the tissues best suited for closure.
Muscle flaps available for coverage of proximal wounds
include the rectus abdominis, the tensor fascia lata, and
the sartorius for smaller defects. In the formidable
problem of deep burns of the groin with exposure of the
external iliac and femoral vessels, closure requires bulky
soft tissues to provide adequate padding and protection.
The inferiorly based rectus abdominis muscle flap has
been found useful in this reconstruction. More distal
defects on the thigh have been reconstructed with the
proximally based tensor fascia lata and the vastus medialis
transposition muscle flaps (6,22). Additionally, Salisbury
and Bevin (22) suggested the use of the distally based sar-
torius muscle flap for coverage of defects of the distal
thigh. They, however, emphasized the need to ascertain
the reliability of the distal pedicle in every patient in
whom the use of this flap is contemplated.
Currently, the fasciocutaneous flap described by
Ponsten (23) and extensively applied to the management
of bum injuries by Tolhurst et al. in 1983 (24,25) has
become the mainstay in the closure of deep bum wounds
in the thigh. The thinness of the fasciocutaneous flap
permits one-staged transfer without undue contour
deformity and has the added advantage of not compromi-
sing functional muscle power (6). Barclay et al. (26), as
well as Cormack and Lamberty (27) described the blood
supply to these flaps as arising through vessels that pass
along the fascial septa between muscle bellies and then
fan out at the level of the deep fascia to form a plexus
from which blood reaches the skin. The posterior thigh fas-
ciocutaneous flap introduced by Maruyama and Iwahira
(28), has been described as versatile in the one-staged
closure of deep bum wounds of the posteromedial and pos-
terolateral thigh. This flap, which is distally based, is sup-
plied by a direct branch of the popliteal artery that emerges
through the fat between semimembranosus and biceps
femoris at the level of the popliteal fossa. Preoperative
angiography or Doppler flowmetry is required to provide
for safer outcome with the use of the flap. The skin
island is designed with its lateral margins situated
between the hamstring muscles and can be raised proxi-
mally as far as the gluteal crease. The donor site, if
< 10 cm in width can be closed primarily (28). A similar
distally based fasciocutaneous flap is the lower posterolat-
eral thigh flap described by Laitung (29). The flap is sup-
plied by the direct cutaneous branches of the popliteal
artery and the lateral superior genicular artery and is also
suitable for coverage of deep bum wounds of the anterolat-
eral and posterior thigh (29).
The Knee
Deep bum injuries in the region of the distal thigh and
upper leg can be compounded by involvement of the knee
joint. When the joint space is exposed, immediate flap
closure is required to prevent infection and loss of

Reconstruction of Burn Deformities
525
function. Myocutaneous and muscle flaps are well suited
for such closures. Witt and Achauer (6) observed that the
advantages of myocutaneous flaps include their ability to
obliterate dead spaces by filling up deep cavities and at
the same time providing stable skin coverage and good
blood supply that accelerates wound healing. However,
the donor site deformity that attends to the use of myocuta-
neous flaps has remained a major drawback. This issue is
partly addressed in the use of muscle flaps with split-thick-
ness skin graft in a single or staged procedure.
The gastrocnemius muscle provides by far the most ver-
satile option in the closure of the opened knee joint. While
the medial head can be designed to reach the anteromedial
aspects of the knee joint, distal thigh, and upper tibia, the
lateral head is suitable for closures over the anterolateral
aspect of the knee joint and upper tibia (30-32)
(Fig. 37.1). The vascular supplies to both heads are rela-
tively consistent. The medial head receives its blood
supply from the medial sural artery, a direct branch of
the popliteal artery while the supply to the lateral head
enters the proximal portion of the deep surface of the
muscle just distal to the popliteal crease. Proximal
exposure and separation of the two heads of the gastrocne-
mius muscle and identification of the soleus fascia are
essential prelude to distal separation and elevation of
either of these flaps.
The major disadvantages in the use of myocutaneous
and muscle flaps include the sacrifice of functional
muscle and the excessive bulk at the recipient site. The fas-
ciocutaneous flaps, which address these issues, are
however only useful where the opened knee joint is not
associated with a deep cavity that requires filling. The
popliteo-posterior thigh and the lower posterior-lateral
thigh fasciocutaneous flaps have both been reportedly
used in closure of such superficially opened knee joints.
Microsurgical transfer of free flaps provides yet another
option for closure of the opened knee joint. Though this
option allows the one-stage use of high-quality distant
tissues, it has been reserved for more severe cases in
which the less complex local options are unavailable.
Figure 37.1
(A) Patient with full thickness bum over the left knee after being trapped underneath a car with knee next to muffler.
(B) Debridement showing open knee joint. (C) Medial gastroncnemius muscle flap for closure around the knee joint. (D) Final result
after closure 1 year later.

526
Functional and Aes thetic Recons truction of Burned Patients
The Lower Leg
The distal part of the lower extremity is poorly
endowed with myocutaneous flaps for pedicled transfer,
particularly for the management of thermal injuries that
usually encompass much larger cutaneous areas (2,3).
Muscle flaps are therefore the workhorses in the closure
of deep burn wounds in this region. Sood et al. (33)
observed that the superior third of the lower leg might
be reliably covered with the gastrocnemius muscle while
the soleus muscle provides a useful flap in the reconstruc-
tion of the middle third of the leg. Coverage of wounds in
the distal third of the leg is a more daunting task with
options limited to the use of the reversed soleus flap or
free tissue transfer (33) (Fig. 37.2). Chang et al. (34) and
more recently, Sood et al. (33) described the use of the
tibialis anterior turnover muscle flap in the coverage of
the exposed tibia following severe burns. This flap,
which had previously been described for coverage of the
tibia following trauma, provides good protection and
blood supply to the underlying bone with minimal donor
site morbidity (35-37).
Several designs of the fasciocutaneous flaps have also
been developed to address specific needs in the leg. In
1985, Moscona et al. (38) introduced the island fasciocuta-
neous flap of the posterior calf. The design followed the
realization that the skin at the base of the fasciocutaneous
flap, which can limit rotation and produce local deformity
at the pivot point, does not provide vascular support to
the distant skin paddle (38). The island fasciocutaneous
flap, therefore, allows the use of the required distal skin
paddle with improved reach making it suitable for cover-
age of defects around the knee joint with minimal donor
site morbidity. In addition, there is no risk of exposure
of vital structures in the popliteal fossa when based
over this area as the proximal skin is left in place. Donor
site closure, however, often requires the use of skin
grafts (Fig. 37.3).
Figure 37.2
(A) A 20-year-old male referred after motorcycle muffler burn over medial aspect of left ankle. Patient referred after
failure of skin grafts for closure. (B) Patient noted to have ostsomyelitis requiring extensive debridement of soft tissue and bone.
(C) Coverage with a gracilis muscle flap. (D) Coverage of flap with a split thickness skin graft. (E) Appearance 1year later after treatment
of osteomyelitis with stable coverage and full weight bearing.

Recons truction of Burn Deformities
Figure 37.3
The island fasciocutaneous flap—divided into
two—proximal random skin flap will cover the popliteal region.
The distal flap is transposed to cover the anterolateral part of the
knee. [Adapted from Moscona et al. (38).]
The saphenous artery fasciocutaneous flap based on the
distal continuation of the saphenous artery onto the lower
leg provides a basis for a posteromedial flap, which can be
used for closure of adjacent defects (39,40). Similarly,
the superficial sural artery fasciocutaneous flap raised
along the center of the posterior calf and as far distally
as the Achilles tendon, can provide closure for adjacent
burn wounds (40). Maruyama et al. (41) introduced the
bilobed fasciocutaneous flaps for coverage of defects on
the leg (Fig. 37.3). This is intended to improve donor
site morbidity by avoiding the use of skin grafts. While
this is a useful technique, it may not be suitable for large
burn wounds.
More recently, Heymans et al. (42) reported the use of
the medial adipofascial flap of the leg for the coverage of
full-thickness burns exposing the tibial crest. The saphe-
nous artery and the posterior tibial artery perforators con-
stitute the blood supply to this flap, which can be
mobilized to cover the whole length of the tibia. While
the donor site is closed primarily, the flap requires cover-
age with split-thickness skin grafts. The old technique of
shaving and overgrafting with thick split-thickness skin
grafts to provide good skin protection over exposed tibia
still has a place in the reconstruction of the severely
burned leg. However, currently dermabrasion has replaced
shaving of epithelial elements. In select cases, this tech-
nique may provide better skin durability and obviate the
need for flap reconstruction (43).
Hammer et al. (44) as well as a number of other authors
have reported satisfactory results with the use of the free
latissimus dorsi flap in resurfacing the anterior surface of
the lower leg in burn patients. The flap is broad, flat, and
can be tailored to fit comfortably into most defects.
Other free flaps suitable for resurfacing the burned lower
leg include the rectus abdominis, serratus anterior, and
the gracilis muscles covered with split-thickness skin
grafts (3,6,45).
The Ankle and Achilles Tendon Areas
Closure of deep burn wounds in the ankle and Achilles
tendon areas present special difficulties since contour pres-
ervation is of utmost importance. Historically, the cross-
leg fasciocutaneous flap provided the principal means of
closure of such wounds (1). The difficulties associated
with this technique, however, ensured the search for
better options. This led to the introduction of the relatively
thin local fasciocutaneous flaps. Masquelet et al. (46) as
well as Clark and Sherman described the lateral supra-
malleolar fasciocutaneous flap based on the perforating
branches of the peroneal artery. The flap is suitable for
coverage of the distal Achilles tendon area and ankle
defects. Several other similar lateral and posterior calf
flaps based on the perforating vessels at the ankle and pro-
viding sensate coverage have been described. Their use in
burn reconstruction may, however, be limited by the extent
of the initial burn injury (48-50).
Today, microvascular free flaps provide the most
adequate means of resurfacing deep wounds in the ankle,
malleolar, and Achilles tendon areas. The thinner fascio-
cutaneous and fascial free flaps are most suitable as they
preserve the normal contour of the region. The radial
forearm free flap, the medial and lateral arm flaps, the tem-
poralis fascial flap, and the scapular flap have all been
reported in the literature (3,51-55). These flaps provide
satisfactory reconstruction so long as nonviable underlying
bony prominences are adequately debrided or decorticated.
The Foot
Fourth degree burns to the foot as may result from elec-
trical injuries are the most likely to present with exposed
tendons, ligaments, and joint structures requiring early
soft tissue reconstruction. The reconstruction must,
however, address the anatomic and functional character-
istics of the specific subunits of the foot. Frequently,
distant flaps are required as the foot, which is functionally
adapted for weight-bearing and ambulation, is provided
with scanty and relatively rigid soft tissues. Hitherto, the
transfer of distant flaps to the foot was achieved by the
527

528
Functional and Aes thetic Recons truction of Burned Patients
cross-leg flap technique first introduced by Hamilton in
1854 (47). The technique, however, is cumbersome and
requires multiple stages of surgery. It is associated with
high morbidity and frequently results in less than
optimal functional and aesthetic outcome. It is not surpris-
ing, therefore, that this technique has now been largely
abandoned (3,26,56,57). Kucan and co-workers (2,3),
however, observed that the cross-leg flap might still be
useful in certain rare instances. They, therefore, suggested
that the technique should be retained in the repertoire of
the burn reconstructive surgeon.
Several thin cutaneous, myocutaneous, and fascio-
cutaneous regional flaps have since been introduced in
the soft tissue reconstruction around the foot. Examples
include the extensor digitorum brevis myocutaneous flap,
and the medial and lateral plantar fasciocutaneous flaps.
These flaps, however, are of limited use in bum reconstruc-
tion where the injury tends to affect large and adjacent
cutaneous areas (3,58-69). Consequently, the microsurgi-
cal transfer of distant tissues has become the gold standard
in bum reconstruction around the foot. The technique has
enabled the importation of large amounts of perfused,
high-quality, and tailored tissue in a single-staged operation.
Other advantages include great flexibility of design, shor-
tened hospitalization, and decreased need for postoperative
immobilization and physical therapy (2,3,6,70). Free flaps
have made significant impact in addressing the difficulties
previously encountered in the reconstruction of the weight-
bearing sole of the foot (71,72). The transfer of free muscle
flaps resurfaced with split-thickness skin grafts has been
acclaimed as the most successful in reconstructing the sole
of the foot and the heel (1-3,72). Kucan and co-workers
(2,3) described the outcome as much more resistant over
time to the shearing forces produced by walking. The flaps
also attach more precisely to the skeletal framework of the
foot maintaining the contour that permits the use of
normal footwear. Free muscle flaps may look bulky initially
but they shrink over time due to the effect of denervation.
This should obviate any need for early debulking or refa-
shioning of a free muscle flap (3). The latissimus dorsi
muscle and myocutaneous free flaps seem to be the work-
horses in lower extremity bum reconstruction (44,73-76).
However, due to considerations for contour preservation,
the thinner fasciocutaneous and fascial free flaps have
been widely used to resurface the dorsum of the foot, when-
ever flap coverage is required. The commonly used flaps for
this purpose include the radial forearm free flap, the medial
and lateral arm flaps, the temporalis fascial flap, and even
the omentum (3,51-55).
A major prerequisite in the use of free flaps is the avail-
ability of suitable recipient vessels in the vicinity of the
wound or defect and yet outside the zone of injury. This
requirement may not be readily met in the severely
burned lower extremity. However, the concept of using
uninjured extremities as free flap carriers to sites with
inadequate local recipient vessels has addressed this
concern to some extent (77-80). The contralateral limb,
where suitable, has been used in lower extremity situations
(81-85). In 1991, Lai et al. (81) reported the use of free
latissimus dorsi muscle flap in the salvage of a limb that
suffered high voltage electrical injury using the contralat-
eral dorsalis pedis pedicle as recipient vessels. Similarly,
Yamada et al. (82) reported the use of the cross-leg free
rectus abdominis muscle flap for lower limb reconstruc-
tions. They described the technique as versatile under
difficult and unfavorable conditions.
Free flaps have been monumental in the salvage and
reconstruction of extensive bum wounds in the distal
lower limb. However, microvascular surgery is most defi-
nitely a team effort requiring highly skilled manpower,
adequate operating facilities, imaging facilities to map
out vascular territories and a sound microsurgical back-
up laboratory.
2.
Early-Onset Functional Impairment
Reconstructive procedures may also be required in the
acute phase of lower extremity bums to prevent or
correct the development of rapidly progressing functional
impairments as well as contour deformities that may
potentially interfere with ambulation and the use of foot-
wear (2,3). Such impairments are often related to problems
of bum scar hypertrophy and burn scar contractures and
are frequently associated with bums of the dorsum of the
foot. Some superficial partial-thickness bums that heal
spontaneously can insidiously develop hypertrophic scar-
ring and contracture over subsequent months if not care-
fully followed. Similarly, when deep partial-thickness
burns that should have been excised and grafted is incor-
rectly diagnosed and allowed to heal over a prolonged
period, scar hypertrophy and contractures are bound to
develop (1). Despite the reluctance to perform surgery
on immature scars, reconstructive procedures may have
to be undertaken early when these abnormalities of scar-
ring result in rapidly progressing functional impairments
or contour deformities. This is particularly true in children
since scar contractures can worsen with time and if uncor-
rected can eventually result in an alteration in the growth
of underlying bones (86).
Hypertrophic Burn Scars
Hypertrophic scarring involving the foot may result in
contour distortion severe enough to interfere with the use
of footwear and impair ambulation. Isolated bums of the
dorsum of the foot tend to result from scalds and grease
bums, which may be associated with increased risk of
hypertrophic scar formation (5). Furthermore, those result-
ing from flame bums often occur as part of larger surface

Reconstruction of Burn Deformities
529
area bums so that the burned foot receives attention only
after life-threatening issues and higher priority areas
have been addressed (5). Deitch et al. (87) noted that a
major functional and aesthetic problem in patients surviv-
ing thermal injuries is the development of hypertrophic
bum scars. They noted that an important factor in the
development of hypertrophic scarring is the time required
for the bum wound to heal. In a series of 100 patients, they
observed hypertrophic scarring in 33% of bum sites when
the wound healed between 14 and 21 days and in 78% of
bum sites that healed after 21 days.
Larson et al. in 1971 popularized the use of pressure gar-
ments in the control and prevention of hypertrophic bum
scars (88-90). Although this concept was soon met with
controversy, it has remained to this day an adjunct in
the control of bum scars. The requirements include the
provision of continuous pressure of the magnitude of
25 mmHg above the capillary pressure and long-term use
of the garments usually for several months. Frequent
careful evaluation is necessary to ensure the effectiveness
of the program. The patient and family members must be
adequately educated on the importance of consistent
home care and compliance. Hypertrophic scars are believed
to be most responsive to pressure therapy in the first 3-6
months when they are immature, hard, and often tender.
Silicone gel inserts were later found to be equally effective
in controlling and preventing the development of hyper-
trophic bum scars (91). Silicone gel was further reported
to soften the matured hypertrophic scar and to decrease
shrinkage and contraction of healed skin grafts. Though
the mode of action of silicon gel is yet to be completely
understood, it certainly does not depend on pressure (91).
Surgical correction is often required for hypertrophic
bum scars. Focal and linear hypertrophic scars of unfavor-
able nature can be excised and the wound primarily closed.
However, the broad and unsightly hypertrophic scar with fis-
sures and recurrent cellulitis may be better served by surgical
excision and resurfacing with thick split- or full-thickness
skin grafts. Splinting in the postgraft period as well as sub-
sequent use of pressure garments may be required in order
to prevent recurrence and enhance functional recovery.
Early Bum Scar Contractures
Burn wounds have been shown to exhibit exaggerated
wound contraction during healing. The contraction has
also been shown to persist within the bum scar tissue par-
ticularly where the scar has remained active and hyper-
trophic (88-90). Over the flexor surfaces of joints, the
force of wound contraction may act in unison with con-
traction of the underlying flexor muscles. The resultant
force can be enormous and capable of resulting in the
development of contractures (88-90). The hip joint,
knee joint, ankle joint, and joints of the forefoot are at
risk of developing contractures following severe lower
extremity bum injuries.
While early mild to moderate contractures may respond
to physical therapy programs, the severe and long-standing
contractures invariably require surgical release. The phys-
ical therapy programs for early less severe contractures
include range of motion exercises and the use of static
and dynamic splints (88-90,92-94). Bennett et al. (92)
as well as Johnson and Silverberg (93) observed that a
fraction of those that fail to respond to these traditional
approaches, may respond to serial casting. This technique
involves casting the deformity in the closest position
toward neutral for the joint. The cast is then changed
at least weekly at which time the deformity is progress-
ively corrected. This accomplishes stretching of muscle,
tendon, and joint capsules and gradually restores joint
function. Splints may be required at the end of the serial
casting to maintain the achieved correction. Serial
casting is particularly useful in the pediatric age group
since the success of the technique does not depend signifi-
cantly on patient’s cooperation (92,93). Bennett et al. (92),
however, noted that serial casting is mostly successful in
large joints with fewer planes of motion and large lever
arms. Serial casting is, therefore, believed to be effective
at the knee joint but less effective in the region of the
ankle joint and the joints of the forefoot.
Dorsal contractures of the foot are also unlikely to
respond to conservative measures. Surgical intervention
is reserved for those deformities, which are likely to be
unresponsive to conservative measures. Early surgical
intervention may be required if the incapacitating late
complication of the rocker-bottom deformity is to be
avoided (2,3). The quality of the overlying soft tissue
scar determines whether a simple incisional release or
complete excision and resurfacing is required. Resurfacing
with thick split- or full-thickness skin graft will usually
suffice. However, when this is less than optimal, flap cov-
erage must be provided. The choice of flap should be based
on local conditions of the foot and available donor sites.
Physical therapy with splints and range of motion exer-
cises as well as the use of custom-made padded shoes
with rigid soles are essentials to obtaining a satisfactory
outcome. Although some authors have cautioned against
surgery on immature bum scars and contractures on the
grounds of high recurrence rates, there are instances
when progressive functional impairments may be better
served by early surgical intervention (94,95).
B.
Late Recons truction
7.
Inadequate Soft Tissue Coverage (Unstable
Scars and Chronic Ulcers)
The major potential problem with bum injuries is the ten-
dency to develop poor quality wound healing by secondary

530
Functional and Aes thetic Recons truction of Burned Patients
intention. This may result in unstable scars capable
of interfering with hygiene and function. Spontaneous
healing following deep second-degree bums in which the
dermis has been partially destroyed results in unstable
coverage that is prone to recurrent ulcerations and hyper-
trophic scarring. The resurfacing of the burned lower
extremity with split-thickness skin grafts meshed to a
ratio >1:2 may also contribute to subsequent scar instabil-
ity (89). Furthermore, pressure ulcerations may develop
over the trochanteric regions, the malleolar regions, and
the heels in patients confined to bed rest either as a
result of the severity of their burn injury or due to intercur-
rent medical conditions.
Chronic ulcerations and unstable scars tend to occur
also in relation to contractures where counter-movement
is retained and in areas prone to repetitive trauma (2,3).
Such areas in the lower extremity include the anterior
aspect of the knee joint, the popliteal area, the anterior
aspect of the ankle joint, the malleolar and Achilles
tendon areas, and the dorsal surfaces of the toes. Under
normal circumstances, these areas are provided with thin
pliable skin overlying scanty subcutaneous tissues. In the
severely burned lower extremity, however, unyielding
scars and skin grafts may be incapable of withstanding
the tension created in the region. Furthermore, in the
region of the foot, skin grafts may fail to provide the
required durability to withstand the stress and strain of con-
stant contact with footwear and ambulation. Kucan and
co-workers (2,3) observed that split-thickness skin graft
coverage of the foot may in the long-term result in hyper-
keratosis along the junction of the graft and surrounding
skin, fissure formation, ulceration, breakdown, and the
development of burn scar contractures. They, however,
suggested that split-thickness grafts may be used in early
coverage to give the patient and surgeon added time to
develop a more adequate reconstructive plan.
Chronic ulcerations are often painful and may impose
the additional burden of management of pain, discomfort,
and drainage to the rehabilitation of the burn patient (89).
Unstable scars can also significantly delay the onset of
physical therapy by inhibiting the use of splints and
pressure garments. This, in effect, may protract the
course of the overall rehabilitation of the burn patient.
The goal of management in patients with unstable scars
and chronic ulcers is to obtain stable and durable soft
tissue coverage. Meticulous care of pressure areas in
patients confined to bed rest will go a long way in prevent-
ing this category of ulcerations (6). In most other cases,
complete excision or dermabrasion of the poor quality
skin and resurfacing with thick split- or full-thickness
sheet grafts will usually give satisfactory results. However,
certain areas are notorious for recurrent ulcerations
and deserve special considerations. These include the
anterior aspect of the knee joint and the reconstructed
weight-bearing sole of the foot. Achauer and Vanderkam
(94) described the unstable burn scar of the anterior knee
as a primary reconstructive problem in which coverage
with skin graft may be too thin leading to unstable cor-
rection. They advocated over-grafting with a medium
to thick split-thickness skin graft or even with a full-
thickness graft. While this may suffice in the adult, it
may not provide the long-term stable coverage required
in the growing child (96). Dhanraj et al. (97) in a review
of the management of recalcitrant knee ulcers in pediatric
patients observed that excessive longitudinal tension
played a contributory role in the etiology of the ulcers.
They demonstrated permanent closure of the ulcers when
the tension in the lower thigh was eliminated by transverse
incisional release and resurfacing with wide sheet split-
thickness skin grafts (Fig. 37.4).
Kucan and co-workers (2,3) observed that the unique
architecture of the skin and subcutaneous tissues of the
sole of the foot is specifically adapted for weight-bearing
and cannot be satisfactorily reproduced by available
reconstructive techniques. They noted that distant flaps
of nonglabrous skin used to resurface the sole of the foot
lack the fibrous elements that bind the normal sole to the
underlying tissues. The transferred tissue is, therefore,
unstable over the underlying bony skeleton and is unable
to resist the shear forces during ambulation. In a recent
survey of various techniques available for the reconstruc-
tion of the sole of the foot, it was noted that the overall
incidence of chronic ulceration in fasciocutaneous flaps
and skin grafted muscle flaps did not differ significantly.
Furthermore, flap sensibility was not different using the
two techniques (2,3). The inference, therefore, is that
these chronic ulcers are mechanical in origin arising
either from untreated osseous abnormalities or from exter-
nal friction due to poor-fitting footwear (2,3). Meticulous
attention to contours while resurfacing the foot should
reduce the problems of shoe-fit and frictional ulcers.
Kucan and co-workers (2,3) observed that aside from
patient selection and postoperative education on the care
of the reconstructed foot, the use of custom-made orthotics
and padded shoes based on computer-assisted gait analysis
are additional factors that enhance long-term successes.
Postburn unstable scars and chronic ulcers in the
lower extremity deserve prompt attention particularly
having been shown to exhibit an increased risk of malig-
nant transformation. The malignancy, which is described
as Marjolin’s ulcer, is a squamous cell carcinoma
(1,98-102). The exact incidence of malignant degener-
ation in burn scars is not known, however, it has been esti-
mated that up to 2% of all epidermoid carcinomas of the
skin originate in burn scars (98). Aarons et al. (98) and
Novick et al. (99) observed a definite predilection for the
flexion creases of the extremities. This is collaborated by
the report of Ozek et al. (100), who in a series of 40 patients