Prevention of Burn Contractures

A burn contractures is an area of skin that has undergone excessive scaring as a result of healing from a deep burn injury. Contractures can begin as a slight puckering of scar tissue, and over time they can worsen becoming thick bands of hypertrophic scars. These tight bands of scar tissue can restrict joint movement, lead to loss of joint mobility and permanently impair normal joint function. Without splinting or pressure pulling, in the opposite direction, such contractures can continue for years after the original burn injury. The longer it takes for a burn injury to heal, the more likely it will form a burn contracture. Contracture is a serious complication of burns and hence all efforts must be taken to prevent contractures.

Measures to prevent Burn contractures

• Covering the burn wound (dressing) early, for the first 2 to 3 weeks.
• Using splints during the day as well as at night.
• Stretching every muscle group that could be affected.
• Positioning the burned limb appropriately.
• Preventing infection by applying topical antibiotic ointment.

1.Dressing and Covering the Burn Wound

Burn wounds beyond minor or above first degrees, requires dressing and a thick covering over it. The aims of covering deep dermal or full-thickness burn wounds, irrespective of their size and depth include:

• Preventing infection.
• Promoting a moist environment that promotes epithelialization.
• Preventing conversion to a deeper burn.
• Allowing/preserving movement and function.
• Assisting in decreasing swelling.

Pressure dressing keeps the burned area or limb in proper position and prevents hypertrophic scarring.

2.Splinting/Orthosis

When the burn wound is over a joint the patient needs to wear a splint over the joint during the day as well as at night to help keep it in a stretched position and to help prevent scarring and contracture. Splinting and positioning must be maintained all the time except when carrying out exercise and functional activities.

Splints when used, assist with healing and to regain range of motion in a joint or joints. They are used to hold parts of the body in the best position in order to:

• Immobilize and protect the skin graft while it is healing.
• Prevent the skin from shrinking and becoming contracted as it heals.
• Soften scar tissue by applying total contact as in facial or neck orthosis.

Hands should be splinted in an anti-deformity position with the wrist extended 20-30 degrees, meta-phalangeal joints flexed 70-90 degrees and Interphalangeal joints fully flexed and thumbs maximally adducted.

3.Stretching

The patient must be assisted to stretch every muscle group that may be affected by a burn contracture, three times a day for approximately 30 minutes. Stretch the muscles that are likely to contract as well as counter-contract. Stretching exercises for different parts of body, where skin is tight may be done as below:

4.Face

• Look into a mirror and make facial expressions like smiling or looking surprised.
• Close eyes tightly and massage skin around eyes.
• Stretch the mouth often and massage the edges of mouth.
• Say alphabets exaggerating the letters with mouth.

5.Neck

• Combine stretching of neck with face stretching.
• Stretch in the opposite direction if tightening present.
• Lie on the back on a bed and look up to stretch the front of neck.
• As the stretch improves, let the head jut out over the edge of bed.

6.Chest

• Lie on the back with a cushion in the middle of your back.
• Start the stretch with your hands on the hips.
• Arch your back.
• Stretch both arms out to the side or over your head to increase the stretch of chest.

7.Shoulders

• Hold a stretch-band with each hand, use one arm to hold and the other arm at the point of pull.
• Repeat to stretch the other shoulder.
• Prop your arm on the back of the couch or chair while sitting.

8.Elbows

• Sit with your elbows all the way straight and your palms facing forward or up.

9.Hands

• Stretch each finger at the knuckle to help get the hand into a fist.
• For finger stretch, wrap your hand in a fisted position.
• To get the hand into an open position, press down against a firm surface.
• Increase the amount of stretch by using the other hand to press down on the back of the open hand.

10.Knees

• To help get the knees straight, sit with your legs propped up.
• Increase the amount of stretch by pressing on your thighs and knees with hands.

11.Ankles

• Standing helps stretch the ankles and to get your feet flatter on the ground.
• Stand on a step as if you are about to go up the steps.

12.Toes

• Toes tend to curl up.
• First massage the scar, then use hands to stretch the toes.

Positioning

A burned limb should always be positioned in a neutral or extend position. Fingers and toes should be bandaged separately from one another and be kept spread. If the palm of the hand is burned, do not bandage it in a fist position, instead spread the hand and fingers as wide as possible. Anti-contracture positioning must start from day one of admission and continue for months.

Positioning of different parts of body

• Neck: Keep sandbags on both sides of head. Position neck in extension with head kept straight. Keep the pillow under the shoulder and no pillow under the head.
• Axilla: Lying and sitting must be with arms abducted (away from midline) at 90 degrees and supported by pillows or foam blocks between chest and arms. Use figure of eight bandaging or strapping to provide stretch across chest.
• Shoulder: Position abducted using aero plane splint.
• Elbow: Keep the elbow in extended position by an extension splint.
• Fingers: Keep the meta-phalangeal joints in flexion and inter-phalangeal joints in extension. Thumb and mid palmar in radial abduction.
• Wrist: Keep the wrist extended with minimal metacarpal flexion and keep the fingers extended.
• Hips: Lying prone with legs extended. Limit sitting and side-lying. Lying supine with legs extended and no pillows under knees.
• Knees: Keeping the legs extended in lying and sitting position, using knee extension splints.

Prevention of infections

Measures to prevent infection include using sterile materials and following sterile techniques for dressing changes and applying bactericidal/antibiotic ointment on wound.

Exercises

Doing range of motion exercises (ROM) help keep the muscles and joints of the burned limbs flexible. For joints that can move in more than one direction, such as wrist, ankle and shoulder, it is important to put them through entire range of motion, for example moving the hand, foot and arm in slow circles. Being active and exercising will help in the following ways:

• Breathing will be easier.
• Help body fight infections like pneumonia.
• Improve flexibility and ability to move.
• Lower the risk of developing scars and contractures that limit the patient’s ability to move.
• Make it easier to carry out everyday activities.
• Give a sense of well-being.

Range of motion exercises

Range of motion exercise refers to activity aimed at improving movement of a specific joint. Range of motion is needed prevent joint stiffness and contractures and should be part of the burn patient’s care from the beginning. These exercises can be very painful in the early stages and therefore requires continuous encouragement and assistance from family.

In the beginning days, it may be passive range of motion where the therapist moves the joint through its full range. As the patient starts to move and ambulate, active range of motion exercise by the patient himself/herself may be started. These exercises should be done regularly, two to three times a day for the affected limbs to preserve movements and to avoid contractures developing.

Basic range of motion exercises are required for prevention of contractures for affected parts such as:

• Shoulder
• Elbow
• Wrist
• Hand and Fingers
• Hip
• Knees
• Foot

Promoting Independence
The sooner a burn patient begins everyday activities, the better will be his/her mobility. Sitting up, getting out of bed and walking will help get out of the hospital sooner. Activities of daily living, when performed by the patient himself/herself, will keep the scar area stretched. Activities such as brushing teeth, combing hair, eating food etc., are activities that promote independence.

Compression garments

As the burn wound and/or skin grafts have healed, compression garments may be worn as long as necessary to prevent hypertrophic scar formation or keloid development. In cases or situations where such garments are not available or possible to use, pressure bandages or crepe bandages can be worn on affected extremities.

Special considerations

• Wound healing process begins soon after the burn occurs and contracture prevention measures must begin from day one.
• Use anti-contracture positioning and splinting from early days.
• Take measures of pain management and prevention of infection.
• As the burn wound heals, the nurse will start rehabilitation measures.
• Assist with physiotherapy/exercises and occupational therapy.
• Treat burned bands with special care to preserve functions.
• Provide assistance and encouragement to maintain anti-contracture positioning all the time, except when carrying out exercises and functional activities.

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
4. Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
5. Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
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7. AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
8. Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/

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