Splinting Techniques for Burn Patients PDF

Splinting Techniques for the Burn Patient  Splints  Splint is an external device to maintain joints in optimal length.  tools made of various material to support burned extremities , maintain joint position and correct deformity. N.B leather , wood, and metal splint...

Splinting Techniques for the Burn Patient  Splints  Splint is an external device to maintain joints in optimal length.  tools made of various material to support burned extremities , maintain joint position and correct deformity. N.B leather , wood, and metal splints have been replaced with thermoplastic. Aims of applying Splints: 1- support burned extremities, 2-maintain joint position. 3-correct and prevent deformities. N.B: * Leather, wood, and metal have been replaced by thermoplastic material. (can be remodeled more than one time according to it’s response to temperature ) Characteristic of splints 1. Non toxic 2. Light in weight 3. Made from non-absorbant material 4. It is padded over bony prominence 5. Easy to be shaped 6. Firm enough 7. Fabricated from non expensive material 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: A- Acute phase: 1) In acute phase of burn injury, splinting required only when damage of tendons and joints is suspected, 2) splinting will immobilize, provide support of affected body parts. 3) If it is used, it should be non conforming and non constrictive securing should be provided due to fluctuation of edema during this phase.(moldable)  B-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. C-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. D-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. Aiming to restore function or ,cosmetic. splinting indications: 1) Protection of anatomical 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. Protection of anatomical structures :  -splints maintain position opposite to anticipated deformity  -splints prevent deformity through maintain R.O.M gained through exercises. 2_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. 3) 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 1. 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. 2. 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. 3.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 4) 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 5) 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 6) 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.  Regional splints 1-Anterior neck region: Anticipated deformity: Flexion with possible lateral flexion. Secondary problems: 1)Disturbance in mastication; 2)distortion of facial units; 3)difficult or hazardous intubation in subsequent reconstructive procedures Splints for neck region.  Soft cervical collar.  Molded neck splint.  Halo-neck splint.  Watusi collar.  Philadelphia collar.  1- soft cervical collar.  Description: it is circumferential foam, rubber orthosis.  Function: Minimal neutral extension (maintain neck in neutral position) , prevent lateral flexion  Advantages: 1- commercial available. 2- Simply to apply and adjust. 3- Comfortable. 4- light weight.  Disadvantages: 1- absorbent. 2- Tendency to rotate around neck. 3- Minimal effectiveness for scar tissue reduction.  2-Molded neck splint:  It is total contact rigid neck support (thermoplastic). Advantages: 1- used in 3rd phase of treatment. 2- low temperature material direct molded. 3- high temp. indirect molded on pt. 4- maintain exact position( prevent rotation and lateral flexion. Disadvantages: 1-Occlusive. 2- Skin breakdown in bony area (pressure point at clavicle and chin). Soft cervical collar Molded neck splint  3-Halo neck splint  Thermoplastic. put the neck in extension using the head and upper torso for stabilization.  Advantages: 1- used in any phase of ttt. 2- allow frequent care of new skin graft. 3- permit visualization of wound.  Disadvantage: 1- Contraindicated for deep burn over forehead. 2- Strapping may cause wound breakdown. 3- Doesn’t prevent shortening of anterior neck secondary to opening mouth. 4- Uncomfortable supine position. Design and molding halo neck splint on patient Custom design halo neck splint  4-Watusi collar:  Series of cylindrical plastic tubes encircle the neck made from thermoplastic material.  To increase degree of neck extension you add additional tubes.  Advantages: 1- applied good contact pressure on the scar tissue so prevent hypertrophic scars. 2- Easily adjusted. 3- Maintain extension and prevent lateral flexion. 4- Can be applied over simple dressing.  Disadvantage: 1- occlusive monitoring needed for signs of maceration of wound. 2- Ridged effect in scar tissue. 3- Allergies to certain material as latex. Watusi collar made from plastic tubes  5-Philadelphia collar.  It is prefabricated circumferential foam or semi rigid positioning material(orthosis). Advantage: 1- commercial available. 2- easily applied. Disadvantages: 1- temporary used. 2- occlusive (pressure point on clavicale ). 3-Only minimal dressing can be worn under the collar. Philadelphia collar  Ear region Anticipated deformity: folding of helix. Secondary problems: auricular chondritis , pressure on damaged ears Splints: 1- Semi rigid oxygen mask: 2- Ear donuts:  It is O2 mask put on the ear and fixed by straps around the head. Advantages: if patient in side lying ,it maintain ear in anti deformity position. Disadvantages : difficulty to Semi rigid O2 mask fix it  Mouth Region Anticipated deformity: *Microstomia, * Ectropion of upper and lower lips. Secondary problems: 1. decreased horizontal and vertical excursion , 2. difficult in mastication ,. 3. altered speech. Splints: 1- Microstomia prevention splint. 2- external traction hook. 3- orthodontic pressure appliance.  Microstomia  prevention splint 1-Microstomia Prevention appliance Component: it’s a metal bar with a valve in the center to increase or decrease the length of this bar. Advantages: help improving the dimensions of the mouth. Disadvantages: -Leads to pressure point on mouth commissure -can’t be used in children. -interfere with eating. -make the mouth opening all the time leading to rolling of saliva out of mouth.  2-External traction hook: Component: it’s a neck splint with side bars & there the is hook attached to these bars from one side &from the other side attached to mouth commissure -Advantages : Improve dimensions of the mouth. -Disadvantages: * Pressure point on mouth commissure *can’t be used in children. *interfere with eating. *rolling of saliva out of mouth.  used to apply horizontal traction to the mouth via surgical tube attached to neck brace. Acrylic (extension traction hook) hook 3- orthodontic pressure appliance * it’s a device inserted in the mouth to maintain stretching of mouth to improve it’s dimensions. *Same Advantages & Disadvantages as previous one.  Shoulder and Axillary Regions Anticipated deformity: Shoulder adduction, extension, and internal rotation. Secondary problems: Development of kyphosis Splints: 1- Axilla or air plane splint. 2- Shoulder abduction brace. 3- Clavicular strap or brace. 4- spinal support.  1- Air plane splint: *component: the thermoplastic splint in the form of (L) letter ,extend from above A.S.I.S to the elbow and may to the wrist. * Advantages: -simple design. -commercially available. *Disadvantages: -pressure point on A.S.I.S. -pressure point at medial epicondyle of humerus. -fixation is very difficult.  Axillary or air plane splint used to position the shoulder in 90 degree  2- shoulder abduction brace: Component: Metal splint. Advantages: *maintain shoulder in flexion ,abduction ,horizontal adduction(anti deformity position) Disadvantages: *expensive. *heavy weight. *pressure point on medial epicondyle of humerus. *can’t be weared under clothes. Shoulder abduction brace with forearm platform positions shoulder while leaving axilla exposed  3- Clavicular strap *It is a strap in the form of figure of 8. Advantages: -prevent protraction deformity. -light weight.  4-spinal support(brace) *Advantages: -prevent kyphosis *Disadvantages: -can’t be worn under clothes.  Elbow and Knee region Anticipated deformity: Flexion with pronation deformity Secondary problems: possible ulnar compression , possible peroneal compression Splints: 1- gutter or trough splint. 2- elbow or knee conformer. 3- 3 point splint 4- spiral extension splint. 5-Air splint 3 point splint  1- Gutter (trough) splint: -it is a hemi cylindrical splint, placed on the flexor aspect of the joint. -Advantages: *very simple. *very light weight. -Disadvantanges: *tendency to rotation around forearm, so it’s difficulty to fix it. *pressure point at it’s sharp ends (to avoid this do flaring of it’s ends).  2-Elbow conformer: It’s the same as gutter splint ,but conformed to the patient size. *Advantages: - prevent flexion deformity. - placed on flexor or extensor aspect. *Disadvantages: -if patient was edematous , when the splint conformed to him it needs to be shaped after resolution of edema. -pressure point on ulnar nerve. -pressure points on it’s ends.  3- 3 point splint It is formed of 2 cuffs, one on the anterior aspect & one on the posterior aspect connected with hinges to maintain the ROM gained. *Advantages: maintain the ROM gained. *Disadvantages: 3 pressure points.  4-spiral extension splint: -It is a thermoplastic splint. -it is spiral shape: starts at anterior aspect of arm. -crossing the elbow from posterior aspect , then lower part on anterior aspect of forearm. *Advantages: -maintain anti deformity position. *Disadvantages: -there are 3 pressure points (ant.arm, elbow, ant.forearm) -it’s difficult to fix it so it’s easy loosed.  5- Air Splint : ** It is a cuff with double layer of plastic , can be inflated to maintain the anti-deformity position. *Advantages: - very simple design. - easy to inspect wound through it because it is formed of transparent material. - help in resolution of edema. - high commercially available. *Disadvantages: -It encloses the wound , so if pressure increase more than the needed amount may lead to laceration of wound.