REHABILITATION CONCERNS FOR BURNS OF THE UPPER AND LOWER EXTREMITIES
Ø Upper extremity
v High-quality acute burn care minimizes early upper extremity reconstructive needs, but problems regularly occur. Perhaps the most common upper extremity deformities are dorsal hand and web space contractures.
§ Dorsal hand contractures are prevented ideally by attention to proper positioning presurgically and postsurgically. If the initial excision was performed tangentially rather than at the level of the fascia (ie, there is some remnant dorsal subcutaneous fat), the release is likely to slide and accept a large piece of skin. The release must result in a resistance-free complete ROM of the metacarpophalangeal joints.
§ Although web space contractures are common deformities that require correction, they can be minimized by proper early surgery and compressive gloves supplemented with web space conformers. In the normal web space, the leading edge of the volar aspect of the web is distal to the dorsal aspect; in the typical dorsal web space contracture, this pattern is reversed (the syndactyly is usually a dorsal deformity). When severe (ie, limiting digital abduction), it should be corrected. The typically normal leading palmar edge of the web space must not be compromised.
v Very deep burns of the elbow are associated commonly with a difficulty in maintaining a complete ROM. Normal elbow ROM is required for performance of ADL such as feeding and toileting.
§ Limited elbow extension is commonly a volar soft tissue issue that responds to simple release; however, heterotopic ossification (ie, when bone forms in the soft tissues around the triceps tendon and interferes with elbow motion, Image 6) also may contribute. Be sure to exclude it.
§ Limited elbow extension is a mechanical problem in which the ROM of the elbow joint is compromised when components of the joint above the abnormal bone.
§ Restricted elbow extension may resolve spontaneously over the course of years, but it should be treated surgically if it interferes significantly with recovery. A careful dissection is required. The bone is removed so that the elbow joint is not blocked; it is important to visualize and protect the ulnar nerve during this dissection.
v Axillary contracture is not uncommon and can interfere with important upper extremity functions (eg, feeding). Axillary release should encompass the entire rotational axis of the shoulder to facilitate complete ROM; the defect is closed with sheet autograft. Postoperatively, abduction splints should maximize the ROM without creating traction or pressure on the brachial plexus or vessels.
Ø Lower extremity
v Patients who have been supine for protracted periods often tolerate immediate upright positioning poorly. Prior to initial efforts at assisted standing, such patients benefit from tilt table training and graduated sitting. Lower extremity edema, which can hinder recovery, is prevented best by using gentle elastic wraps prior to placing the patient in an upright position.
v The most common lower extremity deformities that require correction in patients who have sustained burns are dorsal foot extension contractures, popliteal flexion contractures, and hip flexion contractures. The latter 2 are particularly common in infants and very young children; they spend long periods of time with the hips and knees flexed and are particularly difficult to splint and range.
v A deep dorsal foot burn may result in a contracture of the metatarsophalangeal joints, so that the toes are brought off the ground, causing the patient to have an abnormal gait. When the abnormal gait is severe enough to interfere with ambulation, surgery is required. An incisional release accepts a large piece of split thickness skin, particularly if the initial operation was performed in a layered fashion so that viable subcutaneous fat remains.
v Flexion contractures of the popliteal fossa also interfere with ambulation. Correction generally requires incisional release and grafting with directed postoperative efforts to maintain knee extension. Avoiding injury to the relatively superficial underlying neurovascular structures of the popliteal fossa is important.
v Flexion contractures at the hips are common in infants and very young children who spend little time with the hips in extension. The contracted position of comfort is with the hip in flexion. This deformity interferes with ambulation and should be addressed early in recovery. Avoid injury to the femoral vessels and nerve, as the overlying contracted tissues may distort the normal anatomy.