Why Wait? Initiating Range of Motion the Day After a Skin Graft to the Burned Hand

PURPOSE: The hands are involved in more than 90% of severe burns and are the most frequent site of burn injury. People who sustain burns to the hand experience loss of function that impacts participation in daily activities. Burn treatment includes early skin grafting followed by hand therapy and scar management. There is limited research on best practices in burn rehabilitation. However, after a skin graft the hand is typically immobilized with a splint for 4 to 14 days, and a therapist initiates range of motion (ROM) after immobilization. Traditional burn protocols do not include early mobilization strategies. Early mobilization could provide patients with earlier and improved use of hands after a burn. Therefore, we developed a protocol for Postoperative Day (POD) 1 ROM with an elastic dressing and splint. The purpose of this study was to determine the impact of initiating active ROM on POD1 on hand function and graft success after a burn.

METHOD: We used a retrospective cohort study to explore the effects of initiating active ROM on POD1 after a hand burn with a skin graft. We recruited participants admitted to a burn unit who met the following inclusion criteria: <15% burn, burn treated with a skin graft to dorsum of hand, burn involving ≥2 metacarpophalangeal (MCP) joints, and age 18 years and older.

We applied an intraoperative elastic dressing during skin graft surgery. On POD1, we initiated daily supervised active ROM. Because a majority of participants had a sheet graft, we removed the dressing on POD1 to assess graft integrity. We reapplied the dressing and continued daily supervised ROM until discharge from the hospital. Participants continued a daily ROM program at home.

We assessed skin graft integrity, active ROM, and grip and pinch strength during the next three clinic visits over the course of 1 mo. We documented the percentage of graft success and used goniometry, dynamometry, and a pinch gauge to assess hand function. We used two-tailed paired t tests to detect changes in strength and active ROM between the first and third clinic visits, which included grip, tip pinch, three-jaw chuck pinch, and lateral pinch strength and active ROM at the MCP joint and wrist.

RESULTS: Five participants with seven burned hands completed the study. Early mobilization did not compromise graft success. Graft success rate was 100% on POD1, 95.6% at the first clinic visit, 99% at the second clinic visit, and 100% at the third clinic visit. Participants demonstrated significant improvements in all grip and pinch strength tests between the first and third clinic visit (p < .01). Participants demonstrated significant improvement in extension of the wrist and all MCP joints (p < .05); improvements in MCP flexion were all nonsignificant. By the third clinic visit (M = 25.2 days after surgery), participants averaged 89% and 64% full MCP flexion and extension respectively and 91% and 96% full wrist flexion and extension respectively.

CONCLUSION: The results of this study demonstrate potential for the initiation of early mobilization with people with a skin graft for a hand burn. Early mobilization with an elastic dressing did not interfere with the success of the graft. The possibility of early mobilization after a skin graft could alter the trajectory for functional recovery and ultimately patients’ sense of hope. The small sample size of this study afforded us the opportunity to conduct an innovative trial before we changed current burn practice. Replication of these results in a larger sample would increase confidence in the findings.

IMPACT STATEMENT: This study is important for practice because it challenges the standard burn care protocol by demonstrating potential benefits of early mobilization after a skin graft to the burned hand.

References

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Pan, B. S., Vu, A. T., & Yakuboff, K. P. (2015). Management of the acutely burned hand. Journal of Hand Surgery, 40, 1477–1484. https://doi.org/10.1016/jj.jhsa.2015.02.033

Parry, I., & Esselman, P. C. (2011). Clinical competencies for burn rehabilitation therapists. Journal of Burn Care and Research, 32, 458–467. https://doi.org/10.1097/BCR.0b013e318220c15a