Phala A. Helm

Contractures in burn injury: defining the problem.

This study prospectively examined the incidence and severity of large joint contractures after burn injury and determined predictors of contracture development. Data were collected prospectively from 1993 to 2002 for consecutive adult burn survivors admitted to a regional burn center. Demographic and medical data were collected on each subject. The primary outcome measures included the presence of contractures, number of contractures per patient, and severity of contractures at each of four joints (shoulder, elbow, hip, knee) at time of hospital discharge. Logistic regression analysis was performed to determine predictors of the presence and severity of contractures and a negative binomial regression was performed to determine predictors of the number of contractures. Of the 985 study patients, 381 (38.7%) developed at least one contracture at hospital discharge. Among those with at least one contracture, the mean is three contractures per person. The shoulder was the most frequently contracted joint (38%), followed by the elbow (34%) and knee (22%). Most contractures were mild (60%) or moderate (32%) in severity. Statistically significant predictors of contracture development were length of stay (P < .005) and extent of burn (P = .033) and graft (P < .005). Predictors of the severity of contracture include graft size (P < .005), amputation (P = .034), and inhalation injury (P = .036). More than one third of the patients with a major burn injury developed a contracture at hospital discharge, which highlights the importance of therapeutic positioning and intensive therapy intervention during acute hospitalization. Furthermore, this challenges the burn care community to find new and better ways of preventing contractures after burn injury.

Electrical Injuries: A 20-Year Review

Electrical injuries continue to present problems with devastating complications and long-term socioeconomic impact. The purpose of this study is to review one institutions experience with electrical injuries. From 1982 to 2002, there were 700 electric injury admissions. A computerized burn registry was used for data collection and analysis. Of these injuries, 263 were high voltage (> or =1000 V), 143 were low voltage (<1000 V), 277 were electric arc flash burns, and 17 were lightning injuries. Mortality was highest in the lightning strikes (17.6%) compared with the high voltage (5.3%) and low voltage (2.8%) injuries, and mortality was least in electric arc injuries without passage of current through the patient (1.1%). Complications were most common in the high-voltage group. Mean length of stay was longest in this group (18.9 +/- 1.4 days), and the patients in this group also required the most operations (3 +/- 0.2). Work-related activity was responsible for the majority of these high-voltage injuries, with the most common occupations being linemen and electricians. These patients tended to be younger men in the prime of their working lives. Electrical injuries continue to make up an important subgroup of patients admitted to burn centers. High-voltage injuries in particular have far reaching social and economic impact largely because of the patient population at greatest risk, that is, younger men at the height of their earning potential. Injury prevention, although appropriate, remains difficult in this group because of occupation-related risk.

Heterotopic ossification revisited: a 21-year surgical experience.

Heterotopic ossification (HO) is an infrequently encountered complication of a burn. A retrospective review was undertaken to evaluate our treatment and results. Forty-two patients were identified with HO during 21 yrs. Mean age was 38 yrs. Mean total body surface area and third-degree burn were 55% and 37%, respectively. The elbow was the most frequent site (>90%), and 44% were bilateral. The next most common sites were shoulder, hip, knee, and forearm. Greater than 90% of patients had ventilator support and intensive care unit length of stay 58 and 79 days, respectively. HO was first suspected by decreased range of motion, painful and/or swollen joint, or a nerve deficit. Conventional radiographs were used to confirm the clinical diagnosis. The majority of burns overlying joints with HO were associated with prolonged wound closure because of depth, wound infection, or graft loss. Mean day of diagnosis was 71 days (range, 21–134). Excision of HO was undertaken only when range of motion compromised activities of daily living. Surgery successfully improved range of motion in all cases. The mean elbow arc of motion before and after surgery was 52 degrees and 119 degrees (range, 30–180 degrees), respectively. Seventy percent of elbows were ankylosed. A continuous passive motion device was instituted immediately postoperatively. Local postoperative complications included hematoma, wound dehiscence, infection, and nerve deficit. Maintaining range of motion was difficult for 75% of patients. Symptomatic recurrence of HO occurred in four elbows and one forearm. Because the cause(s) are unknown, prevention is impossible; once diagnosed, medical treatment is problematic and spontaneous resolution is infrequent. Surgery continues to be the recommended treatment when activities of daily living or life style are affected.

Neuropathy after burn injury.

The purpose of this study was to evaluate the incidence of neuropathy in a consecutive cohort of patients with major burn injuries and investigate the clinical correlates for both mononeuropathy and generalized peripheral polyneuropathy. Of 572 patients examined, 64 (11%) patients had clinical evidence of mononeuropathy or peripheral neuropathy or both. Associations of mononeuropathy and peripheral neuropathy with potential risk factors were identified using logistic regression analyses. Electrical cause (odds ratio [OR] = 4.1022, P < .01), history of alcohol abuse (OR = 2.2893, P <.05), and number of days in intensive care (OR = 1.0457, P < .001) were significantly associated with mononeuropathy. The number of days in intensive care (OR = 1.0740, P < .001) and patient age (OR = 1.0543, P < .01) were significantly associated with peripheral neuropathy. This study demonstrates that neuropathy is a common complication of severe burn injury in patients who are older, critically ill, have an electrical cause, or history of alcohol abuse.

Contractures in burn injury part II: investigating joints of the hand.

This study prospectively examines the incidence and severity of hand contractures after burn injury and determines predictors of contracture development. Data were collected prospectively from 1993 to 2002 for adult burn survivors admitted to a regional burn center. Demographic and medical data were collected on each subject. Primary outcome measures include presence of contractures, number of contractures, and the severity of contractures at each of the hand joints at hospital discharge. The metacarpal-phalangeal, proximal inter-phalangeal (PIP), and distal inter-phalangeal joints of all digits and the wrist joints are included in this study. Regression analysis was performed to determine predictors of the presence, severity, and number of contractures. Of the 985 study patients, 23% demonstrated at least one hand contracture at hospital discharge. Those with a contracture averaged ten contractures per person. Most contractures were mild (48%) or moderate (41%) in severity. The wrist was the most frequently affected joint (22%). Statistically significant predictors of contracture development include concomitant medical problems, total body surface area grafted and presence of hand burn and hand grafting (P < .05). Predictors of the number of contractures include length of stay, concomitant medical problems, burn size and presence of hand burn and grafting (P < .05). Contractures of the hand are a significant complication of burn injury. Clinicians can use the contracture predictors to help target interventions for those patients most at risk of developing hand contractures. Given the functional importance of the hand in daily living, the burn care community is challenged to find new ways of preventing and treating hand contractures.

Long-term outcomes in patients surviving large burns: the skin.

The objective of this study was to evaluate persons who have survived severe burns and to describe the long-term residual problems relating to the skin. This is a cross-sectional descriptive study that included a one-time evaluation of 98 burn survivors (18 years old or older) who survived ≥30% TBSA burns, were ≥3 years postinjury, and consented to participate. Study participants were required to undergo a physical examination conducted by the Physical Medicine and Rehabilitation physicians in addition to completing study questionnaires. Participants were predominantly male (63%) and Caucasian (69%). The average time from injury was 17 years (range 3–53 years), and the average TBSA burn was 57% (range 30–97%). Problems with hot and cold temperature, sensory loss, raised scars, and itching continued to pose problems many years after burn injury. Reports of open wounds, skin rash, painful scars, and shooting pain in scars tended to decrease over time, whereas reports of fragile burns, including cuts and tears, tended to increase over time. Findings from the physical examination of the participants include hypertrophic scars in grafted areas (92%) and in nongrafted areas (38%), decreased sensation to pin in grafted areas (71%), hyperpigmentation in grafted areas (53%), fingernail deformities (35%), and skin breakdown (32%). Individuals with large burns deserve more long-term attention. As survivors of large burns continue to face significant burn-related issues, there is a critical need for long-term follow-up both in the clinic and in research.

Return to work after burn injury

The research literature suggests but does not test the hypothesis that differential factors determine when a patient will return to work after serious burn injury. In this study, factors influencing time before return to work after serious burn injury were investigated prospectively as part of a large burn research project. Sixty-five patients with burns who had returned to work were followed. Several variables were examined, including percent total body surface area burned, total percent of partial-thickness burn, total percent of full-thickness burn, duration of treatment, payment source for treatment, sex, race, type of burn, and age. The most significant predictor of time before return to work was percent total body surface area burned, followed by percent body surface area with full-thickness burns, percent body surface area with partial-thickness burns, and number of weeks of treatment, respectively. Sufficient data were available to develop a regression equation to specifically predict time before return to work. The data presented here are useful in informing patients, families, employers, and health-funding agencies as to the probable delay before return to work that can be expected after serious burn injury. In particular, predictability refinements are possible with the regression equation developed in this study.

Serial Casting: A Method for Treating Burn Contractures

The purpose of this study was to assess the effectiveness of serial casting of burn contractures that were resistant to traditional methods of treatment such as paraffin therapy, massage, exercise, and splinting. Serial casting was used to increase the range of motion in 35 joints in 15 patients with burns. A mean increase of 54% was achieved. Casting provided immediate results with minimal complications and was accepted well by patients. Casts were easy to apply and effective even with noncompliant patients. They also delayed or eliminated the need for surgical correction.

Select practices in management and rehabilitation of burns: A survey report

The purpose of this study is to document the organization and current practices in physical rehabilitation across burn centers. An online survey developed for the specific purposes of this study sought information regarding a) logistics of the burn center; b) inpatient and outpatient treatment of patients with burn injury; and c) specific protocols in the treatment of a few complications secondary to burn injuries. Of the 159 responses received, 115 were received from the United States, 20 from Australia, 16 from Canada, and 7 from New Zealand. The overall sample included responses from 76 physical therapists (PTs) and 78 occupational therapists. Seventy-three of those surveyed considered themselves primarily a burn therapist. Nurses (86%) were reported as primarily responsible for wound care of inpatients, followed by wound care technicians (24%). Ninety-seven percent of the therapists reported following their own treatment plans. The trunk and areas of head and neck were treated by both PTs and occupational therapists, whereas the lower extremities continue to be treated predominantly by PTs. Some common practices regarding treatment of a few complications secondary to burn injuries such as splinting to prevent contractures, treatment of exposed or ruptured extensor tendons, exposed Achilles tendons, heterotopic ossification, postoperative ambulation, conditioning, scar massage, and use of compression garments are described. Opportunities exist for 1) developing a common document for practice guidelines in physical rehabilitation of burns; and 2) conducting collaborative studies to evaluate treatment interventions and outcomes.

Restoration of function

Restoration of function is crucial to the performance of activities of daily living, vocational and recreational activities, as well as to community integration and psychosocial aptitude. Strategies to optimize restoration of function include both physical considerations as well as metabolic considerations that can significantly impact physical capacity. Given the breadth of this topic, Drs. Herndon and deLateur focused on two of the most critical facets of restoration of function: metabolic support of the burn patient and exercise/fitness.