A 42-year-old male is admitted to the burn unit after sustaining a 2% total body surface area (TBSA) propane flash/flame burn to the dorsum of his right hand while he was attempting to light a gas grill (Fig. 27-1). The patient's burns were determined to be deep partial thickness burns. The patient is medically stable and is in a non-intensive care unit room. His hand is currently dressed in silver sulfadiazine, gauze, and burn netting. The physical therapist has received orders to evaluate the patient 18 hours post-admission to the hospital.
Deep partial thickness dorsal hand burn.
What examination signs may be associated with this diagnosis?
What are possible complications interfering with physical therapy?
Describe a physical therapy plan of care based on each stage of the health condition.
- BOUTONNIERE DEFORMITY: Rupture of the central tendinous slip of the extensor hood resulting in hyperextension of the MCP, flexion of the PIP, and extension of the DIP
- HYPERTROPHIC SCARRING: Scar that rises above the height of the original area of injury
- SYNDACTYLY: Loss of the dorsal web space through contraction
Understand complications associated with burns to the dorsum of the hand.
Develop a plan of care for each phase of wound healing.
Identify the risks for hypertrophic scarring and interventions designed to minimize its occurrence.
PT considerations during management of the individual with dorsal hand burns:
- General physical therapy plan of care/goals: Prevent loss of range of motion (ROM)/contracture; achieve pre-injury level of strength; maximize functional independence with activities of daily living (ADLs)
- Physical therapy interventions: ROM exercises, stretching, tendon gliding, splinting and positioning, resistance exercise, ADL training, patient education regarding exercise and splint-wearing schedule
- Precautions during physical therapy: No ROM to PIP joints, if the integrity of the extensor tendons is unknown; postsurgical limitations
- Complications interfering with physical therapy: Compartment syndrome, exposed tendons, hypertrophic scarring
In the adult, the hand comprises < 5% of total skin surface area. Even with such a small surface area, there is inherent potential for permanent functional deficits and abnormal scarring after a burn injury. For this reason, the American Burn Association referral criteria for who should be transferred to a verified burn center includes burns to the hand.1 For the clinician treating patients with burns, it is helpful to consider the hand as an “organ” of the body with thin, highly mobile skin on the dorsal surface and thicker, sensory-enriched skin on the palmar surface, and a delicately balanced musculotendinous system.2 Damage to any of these areas from a burn can have deleterious effects for the patient. For detailed descriptions of skin anatomy, burn wound physiology, and the phases of wound healing, please refer to Case 26.
A successful outcome is dependent upon a team effort to ensure timely healing. Superficial partial thickness burns typically heal in less than 21 days if the wound remains infection-free. Deep partial thickness burns can take longer to heal, so the surgeon may elect to surgically excise the ...