I- Some Specific characteristic of hand.II-Problems of burned hand 1-Post burn edema and compartment syndrome 2-Limited joint ROM & deformities. 3-loss of muscle strength. 4-Sensory impairment. 5-Scaring and contracture. 6-Resticated functional use of hand (ADL).III –Evaluation and assessment of burned hand.IV-Different therapeutic approaches for acutely

burned hand.

1-The skin covers the hand is relatively minor portion of total body surface area (TBSA=5%).However it has an exceptional importance because of specific physical qualities, its sensory proprieties, and its microcirculation, which is important for grasping ,manipulating, sensing, and tactile link with environment.

2-The skin on the dorsal surface of hand is thin, elastic, more flexible, and not used as resting or sensory surface. While palmar skin is thick, inelastic, and inflexible palmar surface, and has an important sensory function, therefore dorsal skin sustained full thickness burn injuries when compared with palmaar skin.

3-Palmar skin characterized by alternating thick dermal and epidermal ridges, and anchored to the underlying fascia by fibrous tracts and fatty pads, while the dorsal skin has thin dermis that loosely attached to the underlying tissues this allow free mobility.

4-The palmar skin reach in eccrine sweet glands but not pilosebacous glands while the dorsal skin has reach in pilosebacous system.

5-During burn injuries the hand is exposed part

and usually used as reflex action , with associated flexion this to avoid fair , therefore the dorsal surface commonly involved , and at same time protecting thick palmar surface.

6-Nature of elasticity, independence of tissue layers, and lymphatic composition allow for the edema to accumulate in the dorsum of the hand, and because of superficial structure, therefore the dorsal surface sustained more damage than palmar surface.

7- Damage to anatomical structures in the palm usually occurs during direct contact or electrical burn..

8-The palmar surface sensitive than dorsal surface, and therefore important for texture identification, and tactile link with environment.

9-Hand management dose not mean not only good wound closure but also return of the hand function.

10-The rehabilitation of acutely burned hand depends on depth, location, potential wound healing, sequel and treatment methods, these factors are modified in each case by individual patient's characteristics and compliance.

A-In SPTB, application of topical medicine, Active ROM exercises with elevation, splinting if necessary and if patients is non compliance with exercises program).

B-In DPTB (2ed.Degree), and (Full thickness burn FTB) (3rd degrees burn

Escharotmoy, Fasciotomy, early tangential excision and grafting(e.g Split thickness on dorsal surface, Full thickness on palmar surface). Flap reconstruction (i.e of electrical burn).

Post Burn EdemaDuring the first 48 to 72 hours and

may extend to 5 days, the edema reaches its peak maximum and its degree correlate with depth of burn,(i.e SPTB , edema is minimal and transient , while in DPTB, and FTB , becomes sever and prolonged)( Why?), therefore it is essential to control and minimize hard , immobile edema to prevent ischemia and fibrosis of the intrinsic muscles of hand.

Post Burn Edema

Spontaneous resolution (i.e good wound healing care and proper physical therapy

Non-compromising circulationNo Joint limitation

Compromising circulation Joint limitation

Vascular Insufficiency

What are the clinical signs & symptoms? What are the proper medical management ?

What are proper P.T management?

Mild joint limitation and contracture

Compartment SyndromeWhat are the clinical signs &symptom?

What the proper medical and P.T management?

Moderate to sever joint limitation and contracture

Ischemia & GangreneSever joint limitation and / or amputation

Thermal injuries(Inflammation)

Swelling Increased Fibroplastic activity

Decrease Mobility & Adhesions

Pain

Proximal Interphalangeal Joint Proximal Interphalangeal Joint Flexion DeformityFlexion Deformity

Swan Neck DeformitySwan Neck Deformity

A Stiff surgeon examines patients with burn of the hand and upper extremities at the time of admission for evaluation of burn depth, location , extent as well as physical and occupational therapists. Within 24 to 72 hours of admission a full physical therapy evaluation is performed and include;

(1)evaluation of post-burn edema , (2) active and passive range of motion

assessment, (3) pinch and grip strength,(4)upper extremities strength assessment(5) Two point discrimination a assessment and (6) pain assessment.

Basic principle for positioning of acutely burned hand

1-Positioning of the burned should be closely integrated into a total program for function, if maximal benefits are to be obtained.

2-One of many values of an early positioning program is to reduce edema and maintaining ROM.

3-The positioning program should be individualized to the patients need, however some patients should be in ideal positioning program.

4-The positioning attitude established in first few days post burn may lead to permanent and persistence soft tissue contractures.

5-Hand should be positioned in anti-deformity position and not in functional position.

6-The correct hand positioning should be maintained at all time except for exercises, debridement, activities of daily living

II-Splinting :- 1-Splinting is an extension of

therapeutic positioning in the acute burn period as it prevent and control the contractures, and deformity.

2-The splint should be applied after 48 to 72 hours post-burn.

3- Splint should be used at all time except for exercises, debridement, activities of daily living.

4-Splinting of burned hand should be in anti- deformity position rather thin position of function.

5-For dorsal hand burn the following positioning program recommended.

In general, the following positioning may required for acutely burned hand

Exercises Therapy:-Although positioning and splinting prevent contracture, exercises

are necessary and must be integrated into total program of burned hand in order to maintain maximum functions.

The goals of exercises should be directed toward reducing edema, maintain joint mobility, muscles tone, and promoting functional independence, therefore active and active assisted ROM are recommended.3-The exercises program depend on the extent, depth and location of burn, as all directly affect the degree of joint limitation and muscles states. A- In 1st degree burn (Superficial sunburn):- 1-Patients can often be educated to carry out active exercises

every 2 to 4 hours and gently stretching during day, without any restriction. 2-splinting are not recommended .

B- In 2nd and 3rd degree burn:- The following exercises program recommended;

1-For MCP flexion and extension, keep the IP joint in extension.

2-For PIP flexion and extension, keep the MCP, &DIP joints in neutral position.

3-For DIP flexion and extension , keep the MCP, &PIP joints in neutral position.

4-Strech thumb and web spaces, (abduction and adduction the fingers).

5-For thumb MCP flexion and extension, keep thumb IP in neutral position.

6- Make Hock fist, while making mass flexion to make a complete fist is absolutely contraindicated.

4-All patients should exercise at least 2-4 times daily.5-Several short bouts session of 8 to 10 repetition of

each exercises are often more effective than long single session, and decrease frequency, the later can be used in fibroplastic phase.

6-Exercising during the hubbared tank session is desirable but not always possible.

7-Activity of daily living exercises are important types of exercises , as the main aim of rehabilitation is to return the patient's capacity as maximum , and support psychological state of the patients.8-Forcfull and aggressive passive ROM exercises

are unnecessarily.

9- In case of exposed tendon and joint immobilization is necessary to prevent rupture, however movement of uninvolved joint is necessarily A-Exposure of extensor digitorum communis (EDC)} at the level of MCP joint, of index finger The MCP and wrist should be extended to put

the tendon in maximum slack Gentle passive extension and active flexion of

the PIP and DIP then can be done. No active extension for PIP and DIP can be

done.B-Exposure of the slip of the digit The PIP joint must be maintained in extension

during active flexion of the MCP joints, but active extension of the PIP joint is prohibited

III-Hydrotherapy

One of the most modalities that commonly used for acutely burned hand is hydrotherapy with following principle:- 1-The temperature should not exceed 37 degree. 2-The water should be antiseptic. 3- Duration of application from 10 to 20 minutes. 4-The application of hydrotherapy may be in association with debridment or separated session. 5-development of edema is common after application of hydrotherapy therefore careful attention should be given during session.

IV-Continuous passive motion (CPM):-Recently CPM used for burned patients with following indications;

1-Patients who have extensive burn (large TBSA), involving multiple joints of the upper extremity,

2-Patients who are unable to participate actively in rehabilitation program (e.g decrease cognitive function)

3-When active motion is limited secondary to sever pain and / or anxiety.

The CPM parameter should be set so that the ROM goals are attained and pain is

minimized to achieve this, the following parameters should be considered;

1-The CPM should begin at 2 hours per day, and progress to 8 hours.

2-The patient should fitted in glove or stocknet that the CPM device can be attached.

3- The arc of motion should be within pain free range, after that small adjustment is mad to increase arc of motion.4-The CPM should be employed in conjunction with,

self –care activities, active exercises, and splinting.However the use of CPM for burned patients is limited due to 1-Need of close monitoring (i.e. patients who resist motion of device) 2-Joint insatiability as in extensor tendon rapture. 3-Cost of the machine.

Electrical Stimulation 1- High voltage Pulsed Current (HVPC) 2-Neuromuscular Electrical stimulation (NMES)

Both HVPC &NMES can be used to reduce edema, maintain ROM, and maintain muscles strength.

The treatment usually started at 72 hours post burn for HVPC , with the follwing parameters;

Electrodes Placement:- 1-One active electrodes (negative polarity) were placed over

the median nerve in the anticubital foss, while another electrodes over the ulnar nerve, at medial epicondyle, after being soaked in sterile 0.9% NaCl, while the dispersive electrodes was placed over unburned area. 2-One active electrodes (negative polarity) were placed over

the median nerve in the wrist crises, while another electrodes over dorsum of the hand, after being soaked in sterile 0.9% NaCl, while the dispersive electrodes was placed over unburned area.