Burn Rehabilitation and Reconstruction 

Historically, survival was the only gauge of success in managing those with serious burns. More recently, the overriding objective of all aspects of burn care has become reintegration of the patient into his or her home and community. This objective has extended the traditional role of the burn care team to well beyond completion of acute wound closure. The 3 broad aspects of this effort are rehabilitation, reconstruction, and reintegration.

For excellent patient education resources, visit eMedicine's Burns Center. Also, see eMedicine's patient education article Thermal (Heat or Fire) Burns.

To attain the objective of optimal long-term function, rehabilitation efforts must commence from the outset of burn care. Physical and occupational therapists play an essential role in the acute management of all burn patients, even those who are critically ill and those with large injuries undergoing resuscitation. If a body part is left immobile for a protracted period, capsular contraction and shortening of tendon and muscle groups that cross the joints occur.^[1] This process can occur very rapidly (see the image below).

Ranging and antideformity positioning

Passive ranging and antideformity positioning in the critically ill patient can prevent this. This is best done twice daily, with the therapist taking all joints through a full range of motion. The therapist must be sensitive to the patient's wounds, the status of extremity perfusion, the state of pain and anxiety, and the security of the patient's airway and vascular access devices. Medicating the patients before therapy sessions is often useful to increase their efficacy and decrease their discomfort. These procedures are important but cannot be effectively or humanely performed if they are associated with undue pain and anxiety. Ranging often can be timed to coincide with dressing changes and wound cleansing, minimizing the need for medication.

Of course, the therapist must be aware of the airway and vascular access devices associated with care of the critically ill burn patient. Morbidity and mortality are associated with unexpected loss of these devices. Performing these procedures in coordination with the intensive care unit staff, with full knowledge of the location and function of endotracheal tubes, nasogastric tubes, central venous catheters, arterial catheters, and other monitoring devices, can minimize the risk of their loss. Routine in-service training of therapists facilitates adherence to necessary precautions. The 3 principal priorities for the burn therapist in the acute setting are (1) ranging, (2) splinting and antideformity positioning, and (3) establishing initial contact with the patient and family.

Preventing deformities

Properly performed antideformity positioning minimizes shortening of tendons, collateral ligaments, and joint capsules and reduces extremity and facial edema. Although splints are used less frequently than years ago, several predictable contractures that occur in burn patients can be prevented by a properly performed splinting program. These contractures generally are associated with the flexed position of comfort, except in the hands.

Flexion deformities of the neck can be minimized with thermoplastic neck splints, conformers, and split mattresses. In critically ill patients, positioning the neck in slight extension is often all that can be done. It is also important not to allow ventilator tubing to pull the head such that a contracture develops. If proper care is not taken, a rotary contracture can develop, generally with the patient turned toward the ventilator (see the image below).

Preventing contractures

Axillary adduction contractures can be prevented by positioning the shoulders widely abducted with axillary splints, padded hanging troughs of thermoplastic material, or various support devices mounted to the bed.^[2] Elbow flexion contractures are minimized by statically splinting the elbow in extension. These splints can be alternated with flexion splints to facilitate retention of full range of motion. Flexion contractures of the hips and knees are particularly common in young children but can be prevented by careful ranging and positioning. Flexion contractures are important to prevent even in infants, as they can interfere with subsequent ambulation. Prone positioning, although poorly tolerated by some, can assist in minimizing hip flexion contractures, and knee immobilizers can minimize knee flexion contractures.

The equinus deformity, denoting an extended ankle deformity, is a serious problem that can occur during protracted periods of bed rest with the ankle in extension, even if the ankles are not burned. The ankle flexors shorten and, even in the absence of an overlying burn, disabling contractures can result. However, they can be prevented with static positioning of the ankles in neutral and twice daily ranging. Splints designed for this purpose can cause pressure injury over the metatarsal heads or calcaneus if improperly designed.

These injuries can be prevented using local padding to distribute pressure away from the metatarsal heads and by extending the footplate of the splint beyond the heel and cutting out the area around the calcaneus. Click here to complete a Medscape CME activity on pressure ulcers.

At least twice daily inspection of all splints for evidence of poor fit or pressure injury is important. Improperly used splints can cause injury. Regular splint examination and inservicing of the nursing staff minimizes splint-related skin injury. Positioning burned extremities just above the level of the heart reduces edema and is another important aspect of antideformity positioning.

Establishing a relationship

Finally, the burn therapist's initial assessment and care of those with serious burns is the beginning of a long-term relationship. The therapist should make sure that the patient and his or her family know who the therapist is and understand the essential role of the therapist in their care. Everyone is grateful for regular communication and updates as to progress made and problems encountered. This information helps to ensure compliance with therapy goals. It also fuels the expectation that the patient will again become active and strong upon recovery.

As critical illness abates and wounds are progressively closed, the role of physical and occupational therapists expands and, in many ways, becomes more difficult and challenging. Patients become more aware of what has happened to them and often are fearful of the therapist and the potentially uncomfortable procedures they represent. The principal components of burn therapy that characterize this period include the following:

• Continue passive ranging
• Increase active ranging and strengthening
• Minimize edema
• Perform activities of daily living
• Prepare for work, play, or school

This period can be difficult for both the patient and therapist. Long-term favorable outcomes require hard work during this period. The therapist should not push too hard, but optimal function for the patient is important to achieve. A good program of passive ranging during the period of critical illness greatly facilitates successful retention of normal range during this period. Intraoperative ranging can be useful as well.

Patients commonly undergo surgery during this period and, in coordination with the operating room team, passive ranging can be performed between induction of anesthesia and preparation of the surgical site. Other maneuvers that increase the tolerance of passive ranging include timing of ranging with medication for dressing changes, administration of opiates or benzodiazepines, gentle conversation and encouragement, and an unhurried approach to therapy sessions.

Edema

Burned and grafted extremities commonly have lingering edema that can contribute to joint stiffness. Reduction of this edema facilitates rehabilitation efforts. The use of custom-fitted elastic garments this early after injury is expensive because they frequently need to be downsized as edema resolves. Simply wrapping fingers with self-adherent elastic facilitates reduction of digital edema. Tubular elastic dressings, elastic wrap dressings, elevation, and retrograde massage also contribute to reduction of extremity edema. Topical silicone may have a favorable influence on selected evolving hypertrophic scars.

Focus of rehabilitation

As definitive wound closure nears and hospital discharge approaches, the focus of rehabilitation efforts becomes practical. Activities of daily living and the impending return to play, school, and work are important considerations in rehabilitation efforts. Resisted range of motion, isometric exercises, active strengthening, and gait training are important objectives. When treating children, developmentally appropriate play should be used to facilitate rehabilitation goals. For example, children with serious hand burns are ideally engaged in play that requires the use of their hands at a motor level consistent with their development.^[3]

Rehabilitation goals

The period immediately after discharge from the burn unit is often extremely difficult for patients and their families. In fact, for many burn patients, the first 18 months after discharge is more difficult than the acute stay. The principal rehabilitation goals at this time include the following:

• Progressive ranging and strengthening
• Evaluation of evolving problem areas
• Specific postoperative therapy after reconstructive operations
• Scar management

Ideally, the same therapist that worked with the patient during the acute inpatient hospitalization continues this relationship in the outpatient setting. This both enhances the burn patient's experience and helps the therapist develop a perspective on the process of burn recovery. If, for reasons of distance or managed care, maintaining this relationship directly is not possible, it can be maintained indirectly through regular contact between the therapist and patient at each clinic visit back at the burn unit.

Unfortunately, loss of range and strength during the first months after discharge is not uncommon. This is particularly true if inadequate provisions have been made for outpatient rehabilitation or if therapy during this important and difficult phase of recovery is turned over to a therapist inexperienced with burn care. The burn unit team should monitor the quality of outpatient rehabilitation services at the time of routine clinic visits back to the burn unit. If the patient is losing substantial range and strength from inadequate therapy, readmission for focused rehabilitation efforts is appropriate.

The realities of distance, transportation, and managed care regulations often make it necessary to turn outpatient burn rehabilitation over to less experienced therapists. Methods of helping these therapists do a good job include visits to the burn unit prior to discharge, videotaping therapy sessions (with the patient's written permission), and frequent telephone contact. Family education and involvement with rehabilitation plans may facilitate early identification of evolving problem areas and early institution of corrective focused rehabilitation efforts.

Burn therapists play a central role in planning and performing reconstructive procedures in the months and years after acute discharge. They help to identify needed operations, plan sequencing of operations, and educate patients and families about perioperative care. Planning developmentally appropriate postoperative rehabilitation activities allows the patient to benefit the most from his or her operation.

Scar management is an essential aspect of outpatient burn therapy. Hypertrophic scarring, with its poorly understood physiology, is in many ways the burn patient's worst enemy (see the image below). Perhaps the most virulent hypertrophic scarring is seen in deep dermal burns that heal spontaneously in 3 or more weeks.

This seems especially true in areas of highly elastic skin, such as the lower face, submental triangle, and anterior chest and neck. The wound hyperemia that is universally seen following burn wound healing should begin to resolve approximately 9 weeks after epithelialization. In wounds destined to become hypertrophic, increased neovessel formation occurs with increasing erythema after 9 weeks.^[4]

For more information, visit Medscape’s Wound Management Resource Center.

Methods to modify scar formation

Tools available to modify the progression of hypertrophic scar formation are severely limited both in number and in effectiveness. These interventions include scar massage, compression garments, topical silicone, steroid injections, and surgery. In selected contractures, serial casting may be useful, particularly in the management of established scars that limit the motion of major joints.

Conscientious scar massage can be quite effective in limited areas of scarring and can be performed by family members. This is optimally done several times each day as firm, slow massage of evolving hypertrophic areas after application of bland skin emollients (see the image below). Moisturizers have the added benefit of minimizing the inevitable dryness that accompanies recently healed burns and skin grafts.

Compression garments: Although controversy remains over the issue, a significant weight of opinion and experience supports the contention that compression garments facilitate control of broad areas of hypertrophic scarring,^{[5, 6]} particularly in young children in whom this process seems to be more severe. Compression garments should be worn 23 hours a day until such time as wound erythema begins to abate, usually approximately 12-18 months after injury. Growing young children require frequent refitting and replacement. Garment fit must be verified after manufacture, as a poorly fitting garment is less effective and can be uncomfortable.

Topical silicone: Applied to the healed wound as a sheet, topical silicone has been demonstrated to be effective when applied to small areas of troublesome hypertrophic scar. Some children develop a rash beneath the topical silicone, but this quickly resolves with removal. Ideally, the silicone should be in place 24 hours a day, except for bathing. However, in those who develop a rash beneath the silicone, application 12 hours a day or every other day seems to help. Silicone sheets can be placed beneath compression garments or can be held in place by a number of elastic devices. Firm pressure is not required for the silicone to be effective.

Steroid injections: Steroid injection directly into localized early hypertrophic scars, especially if they are in highly cosmetic locations or are causing extreme pruritus, can be useful. The total dose must be limited so that systemic effects do not occur. These injections are painful, as they require high pressure to infiltrate the dense hypertrophic scars. In children, general anesthesia usually is required. Only localized symptomatic areas are treated in this fashion. As discussed below, surgical excision or incision and autografting is a useful maneuver when routine scar management tools are ineffective.

Extreme pruritus

Unfortunately, extreme pruritus is an all too frequent part of burn wound healing. This typically begins shortly after the wound is healed, peaks in intensity 4-6 months after injury, and then gradually subsides in most patients. It can be very troubling at night. In most patients, it is adequately managed with massage, moisturizers, and oral antihistamines at night. This difficult problem has numerous alternative approaches, though none works reliably for everyone.

In patients who are particularly troubled by pruritus, a sequential therapeutic trial of each maneuver often identifies one that is particularly helpful for that individual. These include allowing the child to gently scratch over compression garments, topical vitamin E-containing creams, topical antihistamine-containing creams, topical cold compresses, frequent application of moisturizing creams, or colloidal baths. Localized highly pruritic scars often respond to a steroid injection.

On rare occasions, pruritus becomes so intense that excoriations develop. These wounds can become superinfected with Staphylococcus aureus that further exacerbates the pruritus. Some of these children are best admitted for wound care and antibiotics to control the pruritus and facilitate healing of excoriated areas. Burn wound pruritus is a difficult, albeit thankfully self-limited, problem that begs for an effective solution.

Proper acute burn care minimizes the need for burn reconstruction. However, even in optimal circumstances, a predictable set of reconstructive operations is commonly required during the first postinjury years. A reconstructive plan is best made collaboratively with the patient and his or her family, the patient's burn therapist, and the surgeon. Although one should not rush in to these procedures, the concept of waiting until all scars have completely matured for more than 2 years prior to embarking on reconstructive operations unnecessarily prolongs recovery.

The physical and emotional trauma of surgery must be balanced against the patient's functional and cosmetic needs. These plans are never easy to develop and must be carefully considered and individualized. No two patients are alike; imagination and patience are important components of planning staged burn reconstruction.

Most burn reconstructive procedures can be performed using a combination of a few basic techniques: incisional release and grafting, excisional release and grafting, Z-plasty, and random flaps. Less commonly needed but useful in selected patients are tissue expansion and free flaps.

Incisional versus excisional release

Most burn reconstructive operations can be performed with an incisional, excisional, or, commonly, combined release, closing the resulting wound with split-thickness autograft (see the image below). The contracture is placed under tension and the release performed sharply. Adjacent areas of hypertrophic scar can be excised if donor sites are adequate to close the larger wound. Full-thickness skin grafts are less likely to contract than thin split-thickness grafts and are the closure of choice in selected circumstances, such as flexion contractures of the digits.

However, full-thickness graft site availability is generally more limited than split-thickness, and thicker split-thickness grafts perform adequately in most situations. In those patients with limited donor site availability, thin split-thickness grafts can be placed over acellular allogenic dermis to enhance results obtainable with thin split-thickness grafts alone.

Z-plasty in burn reconstruction

Although simple in concept, properly planned and executed Z-plasties are powerful reconstructive tools (see the image below).^[7]

The basic steps involved in constructing a Z-plasty include the following:

• Define the line(s) of tension that need to be modified.
• Plan the central limb of the Z-plasty(s) on this line
• Design the lateral lines, if possible, so that they fall along natural skin lines ("Langer" lines) after transposition.
• Design the angle between the central and lateral lines of the Z-plasty to be less than 90° with the lateral limbs curved and no longer than the central limb.

Within these limits, an infinite variety of Z-flaps are possible by modifying the basic concept based on blood supply of flaps and local tissue elasticity. A "5 flap Z-plasty" can be constructed by placing two Z-plasties along the same band, orienting them such that they are mirror images of one another. This results in a fifth "dog ear" flap, which can be inset to insert additional elastic tissue into the band. Multiple Z-plasties can be used in series along a band to excellent effect. The Z-plasty is limited more by the surgeon's imagination than the elasticity of adjacent available tissues.

Tissue expanders and flaps in burn reconstruction

Local flaps, tissue expanders, and free flaps have a more limited but important role in burn reconstruction. Thin random flaps can be raised on the chest wall to cover small fourth-degree wounds of the hands in selected cases, the flap being divided at 3 weeks. More commonly used are groin flaps, which have earned an important role in reconstructing defects, particularly volar wrist defects associated with high voltage electrical injury.

Tissue expanders are useful, particularly in the head and neck. Perhaps most useful are tissue expanders to correct burn-associated alopecia (see the image below). Like tissue expanders, free flaps offer an important option in selected difficult wounds, such as those associated with high-voltage injury and extensive soft tissue loss of the distal lower extremity.

Usually, few reconstructive procedures are necessary in the face, head, and neck during the initial year after injury if deep facial burns have been resurfaced in cosmetic units with thick sheet grafts. The two common exceptions are the ocular adnexa and the neck. The pliant nature of the tissue around the eyes and mouth, combined with the important functions related to their normal position, render these areas at extreme risk for early problems related to tissue contraction. Any contracture that may impede access to the airway assumes a high priority in initial reconstruction.

Other predictable needs relate to lip eversion, microstomia, thickened nasolabial bands, and obstruction or distortion of the nares that occur with progressive contraction and thickening, particularly of deep dermal burns that heal over a protracted period of time (see the first image below). Perhaps the most mobile structures of the face are the eyelids. Therefore, ectropion commonly occurs in the months following injury (see the second image below). Typically, only the skin and subcutaneous tissue are contracted, rolling the other structures away from the globe. Lid elevation is compromised if muscle is injured, unsightly protrusion of periorbital fat occurs if the orbital septum is violated, and coverage of the globe can be threatened if the tarsal plate is damaged. This anatomy must be understood prior to embarking on lid release, otherwise these distorted but normal structures may be injured.

The skin of the anterior neck is thin and elastic. Full-thickness burns in this area ideally are replaced with thick sheet grafts early in the acute course. However, even with the best short-term surgical effort, optimal long-term results are difficult to produce. Even with diligent use of conformers and neck splints, contractures are common with a loss of the normal concavity between the tip of the chin and the sternum. When this becomes functionally important, neck release is indicated. Most patients have a satisfying result with release and split-thickness sheet autografting, although local flaps and tissue expanders provide additional options in selected patients and anatomic circumstances.

Upper extremity

High-quality acute burn care minimizes upper extremity reconstructive needs; however, problems requiring correction regularly occur. Perhaps the most common upper extremity deformities requiring correction are dorsal hand and web space contractures. Dorsal hand contractures are ideally prevented by attention to proper positioning during and after surgery. If the initial excision was tangential rather than fascial, such that some remnant dorsal subcutaneous fat remains, the release will slide and accept a large piece of skin (see the image below). The release needs to result in a resistance-free complete range of motion of the metacarpophalangeal joints.

Web space contractures can be minimized by proper early surgery and compressive gloves supplemented with web space conformers. However, these remain common deformities. 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 is reversed, with syndactyly usually being a dorsal deformity. When severe, they can limit abduction of the digits, thus should be corrected. It is important not to compromise the typically normal leading palmar edge of the web space.

Deep burns of the elbow are commonly associated with difficulty maintaining a complete range of motion. Normal elbow range is required for activities of daily living, such as feeding and toileting. Limited elbow extension is commonly a volar soft tissue issue that responds nicely to simple release. However, heterotopic ossification also may contribute and should be excluded.

Heterotopic ossification occurs when bone forms in the soft tissues around the triceps tendon, interfering with elbow motion (see the image below). Although it may resolve spontaneously over the course of years, if heterotopic ossification interferes significantly with recovery, it should be managed surgically.^[8] It is a mechanical problem in which the range of the elbow joint is compromised when components of the joint abut the abnormal bone. A careful dissection in which the bone is removed such that the elbow joint is not blocked is required. It is important to visualize and protect the ulnar nerve during this dissection.

Axillary contracture is not uncommon and can interfere with the ability to feed and perform other important upper extremity functions. Axillary release should encompass the entire axis of rotation of the shoulder to facilitate complete range of motion. The defect is closed with sheet autograft. Postoperatively, abduction splints must maximize range of motion without creating traction or pressure on the brachial plexus or vessels.

Lower extremity

The most common lower extremity deformities requiring correction in burn patients are dorsal foot extension contractures, popliteal flexion contractures, and hip flexion contractures. The latter two are particularly common in infants and young children who spend long periods with the hips and knees flexed and who are particularly difficult to splint and range.

A deep dorsal foot burn may result in a contracture of the metatarsophalangeal joints such that the toes are brought off the ground, causing the patient to walk with an abnormal gait. When severe, this interferes with ambulation and should be addressed surgically. An incisional release will accept a large piece of split-thickness skin, particularly if the initial operation was performed in a layered fashion leaving viable subcutaneous fat.

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. Be careful to avoid injury to the relatively superficial underlying neurovascular structures of the popliteal fossa.

Flexion contractures at the hips are common in infants and 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 the process of recovery. Be sensitive to the location of the femoral vessels and nerve and avoid injury to them, particularly as the overlying contracted tissues commonly distort normal anatomy.

The ultimate goal of all burn care is reintegration; do not lose sight of this. Burn care does not stop with wound closure. Just a few years ago, the goal of the burn team was survival. It was counted as a success if the patient lived to discharge. This is no longer enough. Ideally, the patient should be returned to his or her family, schoolmates, and community as if the injury had never occurred. Having this goal means respecting the needs of those attempting to return to work and school when planning the timing and type of reconstructive operations. Posttraumatic stress disorder is common in burn patients, and the stress on families is enormous. Look for posttraumatic stress disorder symptoms. Signs include hyper-alertness, nightmares, and chronic fearfulness. Not addressing this common problem compromises recovery.

Rehabilitation and reconstruction of the patient with serious burns is part of acute care. A burn intensive care unit with a separated reconstructive surgery capability simply cannot generate the quality outcomes for burn patients that are now possible. As it is now defined, successful burn care requires hard work by a focused multidisciplinary team over the continuum of care, from resuscitation through reconstruction, rehabilitation, and reintegration.