Splinting Techniques for the Burn Patient

History of splints External splinting has been understood for many years as a means of preventing and correcting burn contractures. As early as 1607, Fabricius Hildanus writes of a six-month-old child who developed a dorsal hand contracture as the result of a mismanaged burn. Following the release of the contracted scar, he splinted the hand in a dynamic flexion splint very similar in principle to those used today

Splints of various materials have been used to support burned extremities, maintain joint position following surgery and correct and prevent deformities. Leather, wood, and metal have been replaced by thermoplastic material. Splinting protocol was first developed by Willis in 1969 which is still used as the basis of therapeutic intervention today.

Significance of splinting techniques The treatment of sever burn cases focuses on:- -Patient survival -The end cosmetic appearance -Functional outcomes which depends on : -Early intervention and prevent further damage -The loss of R.O.M -Disruption of joint integrity Splinting techniques plays important role in preserving functional out come in combination with different treatment available

USES OF SPLINTS IN BURN TREATMENT

Acute phase -In acute phase of burn injury, splinting required only when damage of tendons and joints is suspected, splinting will immobilize, provide support of affected body parts. -If it is used, it should be non conforming and non constrictive securing should be provided due to fluctuation of edema during this phase.

Wound healing phase -Splint may prevent development of contracture and disruption of newly skin graft -Care must be taken to avoid interfere the splint with healing as the result of improper fit or placement as splint has appropriate length of leverage and edge rolled away from skin

rehabilitation phase -Splinting is used to reduce contracture non surgically, prevent deformity, and maintain natural body contours -The combined treatment of splints, exercise, and pressure is required; The ongoing process of scar development and contracture is managed by maintaining sustained stretch to scar tissue. Exercise may Achieve normal ROM and splinting can maintain the range gained.

Reconstructive phase -Splints applied following the release of contractures or reconstructive procedures for restoring function and .cosmoses -Splints are molded directly to the site and should be monitored for evidence of wound maceration or break down.

splinting indications

Protection of anatomic structures -The goal of early splinting is to stabilize the joints so that all external forces are eliminated or reduced. -The joint should be splinted in function position as well as the tendon should be splinted in a slack position to prevent rupture of the tendons. -Special attention for moisten dressing to exposed tendon to prevent drying as well as padding splints to prevent more rupture.

Prevention of deformity -splints maintain position opposite to anticipated deformity -splints prevent deformity through maintain R.O.M gained through exercises. Preservation of skin graft integrity -As survival of skin graft depend on establishment of circulation between underlying wound bed and transplanted graft so splint used to prohibit motion of the joints which locate under or near the grafted area. .

Restore of function The early non operative resolution of contractures provided by sustained stretch and pressure combine with serial splinting to maintain gained R.O.M Splints should be revised to accommodate any change in R.O.M.

Requirements for All Splints

Proper fit A splint too loose and without adequate contour will not maintain proper position. A splint too tight will invite pressure necrosis or nerve compression. Secure application A splint loosely secured with dressings or straps will slide, resulting in poor positioning and possible wound maceration. If dressings or straps are too tight, they will restrict vascular flow and encourage edema.

Avoidance of pressure over a bony prominence If possible, a splint should not be molded over a bony prominence. When such application cannot be avoided, construction should avoid direct contact by doming the splint section over the prominence Periodic removal Splints protecting and positioning an exposed joint or tendon should be removed for wound care only. Prolonged static immobilization can cause joint stiffness, muscle atrophy, or a contracture opposite to the position expected

Daily checking and re-evaluation Changes in edema and changes in the bulk or type of dressings may require daily splint correction in the early stages of treatment. Splint effectiveness also changes as the patient's status changes. A careful daily check will help to avoid splinting problems Cleansing with each re-application Every time a splint is removed for wound care, exercise or for any other purpose, it should be properly cleansed with an antibacterial agent before re-application in order to prevent possible wound contamination

Types of splints

Usage of static or dynamic splinting depends upon the stage of tissue healing. During the early inflammatory stage, static splints are useful, while both dynamic and serial static splints may be indicated during the proliferative stage of tissue healing. Although static and dynamic splints can be beneficial during the stage of scar maturation, serial static splints often prove superior.

Static Splint

-A static splint supports one or more joints in a specific position for the purpose of immobilization. -A conforming static splint is formed directly on the patient in complete contact with the contour of the body distribute pressure a long the length of splints. -Non conforming static splint can immobilize the extremities but accompanied with pressure problem and slippage. -Thermoplastic material is heated and draped directly on the patient, keeping in consideration that the material is safe and comfortable in temperature for patient .

Dynamic splint

-Dynamic splint applies a specific force in specific plane of motion through elastic traction. -It should be considered for these joint demonstrate the most resistance to passive stretch and don't respond to positioning or intermittent stretching techniques. -Prefabricated dynamic splint are used widely in burn rehabilitation, it is available for different body regions, it is worn in the presence of open area, exposed tendons. -For the best result, dynamic splint can be worn continuously with gradual increase tension at level where the patient can tolerate , and only removed for short period of time for wound care.

Splinting in the Operating Room

-The patient's most painful period is usually prior to grafting, due to exposed nerve endings. If the splint is fabricated during partial anesthesia, joints can be positioned more easily and painlessly. -Following grafting of deep partial or full thickness burns, immobi­lization is essential to prevent displacement or shearing of the graft while maintaining the graft at its fullest excursion. All joints above and below the graft should be immobilized until the graft is stable.

-A location adjacent to the operating room should then be designated and approved for the therapist's use, splinting must be done quickly and efficiently. -Needed information, charted by the surgeon, includes the procedure to be done, the area to be grafted, the donor site, and whether the patient will require splints. Using this information, the therapist can then determine whether the patient will be prone or supine on the operating table, and what type of splints will be required.

-As soon as the reversal of anesthesia begins, splint application should begin. To make the best use of the time before the patient is alert, contour molding can be done in segments and secured with light gauze wrap. Splints applied in the operating room should be of simple design for rapid molding so as not to extend the operating room or anesthesia time. -A small portable water heating source, such as an electric skillet, should be set up about a half-hour before splinting time to allow water to reach proper working temperature. Splint heating should begin as final dressings are being applied to the patient.

Regional splints

Anterior neck region Anticipated deformity: Flexion with possible lateral flexion. Secondary problems: Disturbance in mastication; distortion of facial units; difficult or hazardous intubation in subsequent reconstructive procedures.

Soft cervical collar

(A) Anterior view: (B) Posterior view:Patient wearing soft cervical collar and clavicular strap.

Molded neck splint

Neck splint custom-made from thermoplastic material

Design and molding halo neck splint on patient

Design and molding halo neck splint on patient

Custom design halo neck splint

Watusi collar made from plastic tubes

Watusi collar made from plastic tubes

Philadelphia collar used for positioning neck

Ear region Anticipated deformity: folding of helix. Secondary problems: auricular chondritis , pressure on damaged ears

Semirigid oxygen mask used to protect tissue of burned ear from pressure.

Mouth Anticipated deformity: microstomia, ectropion of upper and lower eye lids. Secondary problems: decreased horizontal and vertical excursion , difficult in mastication , and altered speech

Microstomia Prevention appliance in place

Microstomia prevention splint fabricated from stainless steel wire, thermoplastic material and rubber band

Acrylic hook used to apply horizontal traction to the mouth via surgical tube attached to neck brace .

(A) Orthodontic commissure appliance. (B) appliance in place

Shoulder and axillary region Anticipated deformity: Shoulder adduction, extension, and internal rotation. Secondary problems: Development of kyphosis

Axillary or air plane splint used to position the shoulder in 90 degree

leaving axilla exposed Shoulder abduction brace with forearm platform positions shoulder while leaving axilla exposed

Shoulder abduction brace

Figure of Eight bandage

One type of splint support brace used to correct trunk postural deviation

Elbow and Knee region Anticipated deformity: Flexion with pronation deformity Secondary problems: possible ulnar compression , possible peroneal compression

Gutter or trough splint to maintain joint extension

Three point splint for elbow extension

Three point splint for elbow extension , the anticubital fossa remain exposed

Posterior knee extension splint

A type of spiral splint looped around upper extremity to promote elbow extension

Transparent appliance constructed of two layers of plastic that provides immobilization and compression when inflated

Wrist and Hand region Anticipated deformity: Extension or hyperextension of the MCP joints; flexion of the IP joints; boutonniere deformity; adduction and flexion of the thumb; flexion or extension of the wrist Secondary problems: Radial/ulnar deviation; abduction of the little finger;. flattening of the palmar arches; finger adduction with syndactyle extension of the IP joint of thumb

Anti deformity hand splint

Wrist splint maintain wrist in extension while the fingers are free to move

Thumb positioned between palmar and radial abduction with a thumb spica splint.

Thermoplastic material conformed along index and the thumb to maintain thumb web space and secured in place by foam straps

(A) Palmar extension splint for right hand. (B) Dorsal extension splint with padding and secured with cohesive wrap

Traction splint post mesh skin graft, finger traction is applied by rubber bands attached to dress hooks to finger nails and secured to ends of splint

Halo hand splint made from wire outrigger attached to thermoplastic forearm base.

flexion glove assist with finger flexion through elastic traction

(A)-Sandwich splint secured with cohesive wrap to maintain extension of digits (B)- bivalved sandwich splint to maintain finger in flexion position

dynamic splint Hand

dynamic splint Hand

Hip and Perineal region Anticipated deformity: flexion; adduction Secondary problems: Altered gait pattern; difficulty with straddle position

Anterior hip spica splint made from thermoplastic material to maintain hip extension and abduction while preventing hip flexion and adduction.

Hip :abduction splint made from thermoplastic material secured in place by foam strap

Spreader bar attached to knee gutter splints to maintain abduction

Ankle and Foot region Anticipated deformity: Dorsiflexion; planter flexion Secondary problems: Shortening of Achilles tendon; equinus deformity: altered gait pattern

Posterior foot drop splint-nonconforming Posterior foot drop splint-nonconforming. Heel section cut away to relieve pressure and stand applied to splint to elevate heel off bed

Posterior ankle conformer with heel section flared away for pressure relive, splint secured in place by elastic bandage

Anterior ankle conformer .

High top gym shoe with metatarsal roll-off added to sole of

Molded leather shoe with Velcro closure and metatarsal roll-off added to sole of shoe.

Toe conformer splint shaped to cover the dorsal Toe conformer splint shaped to cover the dorsal .surface of toes to prevent hyperextension. Can be secured with cohesive Wrap or elastic bandage.