# Upper Limb Orthotics/Burns injury on the dorsal surface of the wrist
## Describe your case study

A 20 year old student had a burn injury on his right hand from a hot water. The accident happened one week ago (1/52) at a camping picnic arranged by him. The scenario starts when he was about to prepare an early morning breakfast for others. He slipped just next to the turned on stove; which had a very hot tea pot on it. The tea pot spilled on the dorsum surface of his right hand and left him with a deep partial thickness burn injury.
The presenting complication was burn injury extended from the metacarpophalangeal joints; all the way across the wrist joint proximally 20 cm onto the forearm. Extension contracture was developed on the wrist joint 40˚ degrees, hyperextension in the metatarsophalangeal joints, and 10˚ degrees Redial deviation contracture. The patient is on Morphine, and there is no evidence of any graft/flap intervention.
Despite the burn injury he regained a normal upper limb function. The patient is right hand dominant, and he lives alone in a flat close to his university. He would like to play piano again and be able to practice his activities of daily living independently.

### Introduction

Historically treatments of burns injury had been discovered and evolved a long time ago. There is evidence proving the involvement of the Neanderthal to treat burns injury for over than 3500 years (Herndon, 2012, p. 1). According to Herndon (2012), documentations form the Egyptian in 1500 BC and from the Chinese in 1600 BC had been found which explained their ways to treat burns injury. Nowadays with the massive developments of the medical sectors; Burns injury treatment and rehabilitation are sophisticated and occupies high ranking among the other medical areas.

### Evidence

Prescribing the best available rehabilitation treatment option for any type of burns injury is complicated. Clinicians should have an insight and understanding of the principles of these injuries to be able to distinguish between the different types of the burns injury and their healing mechanism. Consequently, the way of the rehabilitation approach for each type of burns injury will be very specific (Radomski & Latham, 2008, p. 1243). The previous case study represents one of the cases that should be analysed from all aspects in order to prescribe a useful orthotics treatment. This will enable the patient to practice the activity of daily living independently, and facilitate the healing process.
Anatomically, human skin is representing 7% of the total body weight in the average adult (Marieb & Hoehn, 2007, p. 152). It consists of epidermis which is the outer layer of the skin and has five different types of cells. The thickness of epidermis is different according to the location and function, for instance in the finger tips and palms the skin is thicker than the dorsum of the hand. The second layer is called dermis, which contains nerves ending, vessels, hair follicles, sweat glands and oil glands. The last two layers respectively are subcutaneous tissue layer which contains fat and it’s responsible for regulating the body temperature and then the muscles tissue layer (Marieb & Hoehn, 2007, p. 152-159).
Pathologically, once the burn happens the body will react by attempting to reduce the heat by dilation of the body vessels, the skin then becomes erythematous. Burns Injury will occur with additional heat to the same spot, which will then increases the permeability of the blood vessels. Consequently, the plasma will leak out from the vessels into the surrounding tissue. The local circulation becomes sluggish, which leads to the death of the cells (Leveridge, 1991, p. 10).
There are many types of burns; chemical, electrical, radiological and thermal burns which include flash, flame, contact and scalds burns injury (Herndon, 2012, p. 37&70). Leveridge (1991, p. 7), has defines the scalds burns injury as “the burns that produced by moist heat”. Hot water burns injury is considered one of the scalds burns injury, it’s an unintentional injuries that could lead in many cases to very serious consequences. Exposing the human skin for a water temperature of 60˚C for five seconds only; can lead to a partial thickness burn (Leveridge, 1991, p. 8).
The degree of the burns severity fundamentally depends on the thickness of the affected skin. In a deep partial thickness burns injury; the cells of epidermis and superficial layers of the dermis would be severely damaged (Radomski & Latham, 2008, p. 1245). According to Herndon (2012), the injury site would be very painful as the nerves ending would be more exposed and much sensitised to any stimuli. He also indicates that the pressure sensation would be intact, while the light-touch sensation is diminished. In addition, the patient would experience deep achy pain related to the inflammatory response (Herndon, 2012, p. 578).
According to Radomski & Latham (2008), the spontaneous healing process in a deep partial thickness burns injury believed to be sluggish; it could takes between three to five weeks. They indicate that the impairment of the dermal layer which has vascular content is believed to be the reason behind the slow rate healing process. Consequently, the risk of hypertonic scar formation would increase as the spontaneous healing process is decreased in speed. This will result in developing contractures and deformities; which will effects the patient quality of life significantly (Herndon, 2012, p. 635). Herndon also indicates the effectiveness of using a compression/pressure garment therapy with a conforming orthotics for a deep partial thickness burns injury. A significant reduction of the scar formation would occur and prevention of contractures or deformities.

### Orthotic treatment options

The principle role of orthotic treatment in burns injury is to prevent contractures and deformities, and maintain the range of motion that could be achieved by the physiotherapy/ occupational therapy either pre- or post- surgery intervention (Turner, et al. 1996, p. 283). According to Holavanahalli et al. (2011), there are two different opinions provided in the literatures regarding the application of the antideformity splint for burns injury patient. The first school suggests the splint application before the contractures occur as prevention, while the second school suggests the application of such splint if there is any reduction in the passive range of motion (Holavanahalli et. al, 2011).
As a clinician having a patient with a deep partial thickness burns injury on dorsal surface of the right wrist, I would initially assess the range of motion of the wrist joint and Metacarpophalangeal joint and compare it with his left side. Inspect carefully the level of sensation in the finger tips by conducting some neurological tests. As the presenting complication has an explicit extension contracture on the wrist joint for about 40˚ degrees, hyperextension in the metatarsophalangeal joints, and 10˚ degrees Redial deviation contracture. I would prescribe the resting position/ intrinsic-plus position orthotic with neutral wrist position as it would be the optimum position for the wrist joint and hand to prevent the contracture (Radomski & Latham, 2008, p. 467).
According to Turner, et al. (1996, p. 267), the resting position/ intrinsic-plus position orthotic should maintains the wrist joint in 20˚- 30˚ degrees of extension (modified to neutral or 10 ˚ degrees only for this case), metacarpophalangeal joints in 70˚ degrees of flexion, interphalangeal joints in full extension, thumb opposed and extended, and web space and palmar arches are maintained. There are many evidences proved the benefits of using resting position splint to reduce the burns injury oedema (Kowalske, 2011). However, Kowalske (2011), also suggest the once the burns injury initially healed or covered; the patient might be able to mobilize his hand actively. Then an alternative splint should be customized to accommodate and maximize the range of motion.
Many studies have shown the impacts of the delay in prescribing a new splint design, which supports and increases the biomechanical advantage of the hand after the healing has occurred. Dewey et al. (2011), points out the impacts of prolonged resting position. They recommended using the resting position splint as a night splint after the wound is completely covered. Dewey et al. (2011) believed that tightness of the intrinsic muscles of the hand could occur with prolonged resting position, which could create other deformities for instance, swan-neck deformity.
An alternative option to the orthotic testament would be the application of the serial casting method with plaster or fibreglass bandages. This option is mainly used to correct 30˚ degrees contractures and above, which is considered a significant contracture (Herndon, 2012, p. 628). According to Herndon, a new material has been recently introduced to be an alternative casting material; it is non-latex polyester such as Delta-Cast. Richard et al. (2009), indicate in their paper that the indication of serial casting is if the patient is not cooperative, does not accept the splint, and in a grafting intervention that requires protection and immobilisation.
However, for the previous case study I would apply the splinting method in a resting position/ intrinsic-plus position or antideformity position. I would use low temperature thermoplastic material including the two-thirds of the forearm length, the wrist joint, and the whole hand joints. I will keep in my consideration that this splint’s design will be subjected to some changes after 2 to 3 weeks from the incidence if the wound will be completely covered.

### Comparison of orthotic treatment options

The previous case study represents a condition that has high controversy amongst the researchers of the medical field. According to Kowalske et al. (2007), some researchers argued that the outcomes from skin grafting/ flap intervention for deep partial thickness burns injury, is better in terms of accelerating the healing process and consequently decrease the rehabilitation time. However, Herndon (2012, p. 635) indicates that spontaneous healing could increase the chances of hypertonic scars to be formed in the deep partial thickness burns injury. Accordingly, the patient would be vulnerable to develop contractures and deformities which will affect his quality of life and reduce the level of activity and independence.