Annals of Burns and Fire Disasters - vol. XIII - n. 3 - September 2000

THE IMPORTANCE OF EARLY PHYSICAL THERAPY TO PREVENT CONTRACTURE IN THE BURNED HAND

Petronic I., Nikolic G., Markovic M., Marsavelski A., Golubovic Z., Janjic G., Cirovic D.

University Children's Hospital, Belgrade, Yugoslavia

SUMMARY. Keloid scars are most commonly observed after full-thickness and second-degree burns. Keloid scars are commonly localized on the limbs, face, and neck because of the exposed nature of these parts. A prospective investigation was conducted at the University Children's Hospital in Belgrade over a three-year period, during which 35 children with hand burns were treated. Early physical therapy consisted of electrokinetic therapy, corrective orthosis, and the application of elastic bandages. In the late phase, working hydrokinesia and occupation therapy were performed. After physical therapy the outcome was followed up. A significant number (67.7%) of immature scars healed, unlike mature scars, which had to be managed surgically. Treatment aimed at the aesthetic and functional improvement of the hands. It should be noted that favourable aesthetic results and a full range of movement were achieved only in cases where physical therapy was applied simultaneously with wound epithelializafion and initiated as early as possible in collaboration with the surgeon.

Burns have an important place in the pathology of children in relation to their frequency and gravity. The severity of burns in children is also related to the fragility of the child's organism so that an area of burned surface that does not represent severe injury in an adult may be very dangerous for a child.
The incidence of keloid formation after burns ranges from 6 to 9%. Numerous methods have been used with greater or lesser success (e.g. atraumatic excision, irradiation, local infiltration of corticosteroids with or without excision, cryosurgery) for the prevention and treatment of keloids. The aetiopathogenesis continues to be obscure.
The basic purpose of the application of certain agents of physical therapy is to prevent the development of hypertrophic or keloid scar after treatment of the burn. Besides their poor aesthetic appearance, keloid scars may endanger joint functioning. Physiotherapy primarily makes it possible to maintain a full range of movements and functioning of the affected joints.

During the three-year period 1996-1999, at the University Children's Hospital in Belgrade, we treated 35 children with scars secondary to burns of the hand. After completion of the surgical treatment of the bum, i.e. when epithelialization begins, we carefully examine the burn surface and investigate the functional state of the surrounding joints. At the first sign of compromised function or attraction of the surrounding healthy tissue, we initiate physiatric therapy in an attempt to discontinue the formation of keloids and to promote the regression of any already existing.
Electrotherapy is applied by potassium-iodide electrophoresis, with iodide solution 1 % as an active substance locally instilled by the biological effect of a galvanic current. Electrophoresis is conducted in a series of 15 consecutive applications with pauses of two weeks and repeated in several series if needed. Besides electrophoresis, regular kinesitherapy is also necessary.
Kinesitherapy is initiated by active exercises and continued with actively supported and passive exercises in all cases of scarred joint surroundings. Therapeutic exercises are used for the prevention of contractures, muscle atrophy, tendon coalescence, shortening of the joint capsule, and oedema, while the circulation and lymph drainage are improved.
Occupational therapy with rings and toys is also very important in cases of hand scarring. Thermotherapy is less frequently used since heat influences long-term hyperaemia, and longer perfusion may have an adverse effect, i.e. promotion of keloid growth. We applied thermotherapy very carefully in cases of hand burns and finger bums, when fixed contractures had already developed. Thermotherapy, i.e. paraffin compresses, was used as an initial procedure.
We always used elastic bandaging for the scars since the extent of keloids can be reduced by permanent controlled pressure` In cases of involvement of joints in the extremities, we applied corrective splints that maintained or increased the range of movement in the given joint.

The majority of burns in the 0-3 year-old group were sustained by the child pulling on an object or during play and play-learning behaviour. Contact with hot solids was in second place. Burns caused by flame were of significant importance in the older age group. This explains why the most frequent localization of scalding was the upper limbs, trunk, and face. Keloid scars were commonly localized in the limbs, face, and neck, because of the greater exposure of these parts (Table 1). We treated 35 children with scars induced by burns in the hand. Keloid scars were most commonly noted after full-thickness burns (84.21 %) and deep second-degree burns (63.93%).

After physical therapy had been conducted a significant number of immature scars were found to have healed, contrary to mature scars, which had to be managed surgically (Figs. 1,2).

In immature keloids leading to extensive functional disorders, surgical therapy is initiated earlier in order to prevent degenerative processes around the joints. Mature (older) keloids cannot in practice be conservatively treated. In such cases surgery must be performed and followed by prolonged physical therapy (Table II).

Discussion

The aim of this work is to point out that in spite of successful treatment, the later phase of burned children's lives may be affected owing to concomitant consequences. It should however be noted that favourable aesthetic results and a full range of movement were achieved only in burns where physical therapy applied simultaneously with wound epithelialization.
The prevention of invalidating injury starts with medical rehabilitation during medical treatment and continues with the training of family members for continuation of the treatment at home.

RESUME. Les cicatrices chéloïdales se manifestent le plus communément à la suite des brûlures à toute épaisseur et des brûlures de deuxième degré. Elles sont localisées principalement sur les membres, le visage et le cou, à cause de la majeure exposition de ces parties du corps. Les Auteurs ont effectué une étude prospective pendant une période de trois ans, pendant lequel 35 enfants atteints de brûlures de la main ont été traités dans l'Hôpital Universitaire des Enfants à Belgrade. Les premiers soins physiques consistaient de la thérapie électrokinétique les orthoses correctives et l'application de pansements élastiques. Dans les phases successives les Auteurs ont utilisé l'hydrokinèse du travail et la thérapie occupationnelle. Après la thérapie physique les patients ont été suivis et un nombre significatif (67,7%) des cicatrices immatures sont guéries, contrairement aux cicatrices matures, qu'il fallait traiter chirurgicalement. Le but du traitement était l'amélioration esthétique et fonctionnelle des mains. Il faut noter que les résultats esthétiques positifs et la capacité totale de la mobilité ont été possibles seulement dans les cas où la thérapie physique et l'épithélialisation ont été efféctuées en même temps et avec le moindre délai possible en collaboration avec le chirurgien.

1. Melhom J.M., Homer RX: Bums of the upper extremity in children: Long-term evaluation of function following treatment. J. Pediat. Orthop., 7: 563-7, 1987.
2. Mercer N.S.C.: Silicone gel in the treatment of keloid scars. Br. J. 9. Plast. Surg., 42: 83-7, 1989.
3. Strasser M.: Creative use of metal rings in hand therapy. J. Burn Care Rehabil., 4 : 350-1, 1989.
4. Israel D.J., Heydon K.M., Edluch R.F., Pozos R.S., Wittmers L.E.: Core temperature response to immersed bicycle ergometer exercise at water temperatures of 21, 25 and 29 °C. J. Burn Care Rehabil., 4: 336-44, 1989.
5. Kaufman T., Nawman R.A., Weinberg A., Wexler M.R.: The Kerlix tongue-depressor splint for skin-grafted areas in burned children. Innovat. Burn Care, 5: 462-3, 1989.
6. Schnebly A.W., Ward S.R., Warden D.C., Saffle R.J.: A nonsplinting approach to the care of the thermally injured patient. J. Burn Care Rehabil., 3: 263-6, 1989.
7. Wilder P.R., Doctor A., Palsy J.R., Saunders J.T., Edlich F.R.: Evaluation of cohesive and elastic support bandages for joint immobilization. J. Burn Care Rehabil., 3: 258-62, 1989.
8. Wright M.R., Taddonio T.E., Prasad J.K., Thomson P.D.: The microbiology and cleaning of thermoplastic splints in burn care. J. Burn Care Rehabil., 1: 79-82, 1989.
9. Ward R.S., Schnebly W.A., Krantz M., Warden C.D., Saffle J.R.: Use of positive plaster impressions to facilitate measurement of anti-burn scar support gloves for the severely burned hand. J. Burn Care Rehabil., 4: 351-3, 1989.
10. Ward R.S., Schnebly A., Kravitz M., Warden C.D., Saffle J.R.: Have you tried the sandwich splint? J. Burn Care Rehabil., 1: 835, 1989.