Splinting TechniquesSplinting Techniquesfor the Burn Patientfor the Burn Patient

History of splintsHistory of splints

External splinting has been understood for many years External splinting has been understood for many years as a means of preventing and correcting burn as a means of preventing and correcting burn contractures. As early as 1607, Fabricius Hildanus contractures. As early as 1607, Fabricius Hildanus writes of a six-month-old child who developed a writes of a six-month-old child who developed a dorsal hand contracture as the result of a mismanaged dorsal hand contracture as the result of a mismanaged burn. Following the release of the contracted scar, he burn. Following the release of the contracted scar, he splinted the hand in a dynamic flexion splint very splinted the hand in a dynamic flexion splint very

similar in principle to those used todaysimilar in principle to those used today

Splints of various materials have been used to support burned Splints of various materials have been used to support burned

extremities, maintain joint position following surgery and extremities, maintain joint position following surgery and

correct and prevent deformities. Leather, wood, and metal correct and prevent deformities. Leather, wood, and metal

have been replaced by thermoplastic material. Splinting have been replaced by thermoplastic material. Splinting

protocol was first developed by Willis in 1969 which is still protocol was first developed by Willis in 1969 which is still

used as the basis of therapeutic intervention todayused as the basis of therapeutic intervention today . .

Significance of splinting techniquesSignificance of splinting techniques

The treatment of sever burn cases focuses onThe treatment of sever burn cases focuses on-:-:

--Patient survivalPatient survival

--The end cosmetic appearanceThe end cosmetic appearance

--Functional outcomes which depends onFunctional outcomes which depends on: :

--Early intervention and prevent further damageEarly intervention and prevent further damage

--The loss of R.O.MThe loss of R.O.M

--Disruption of joint integrityDisruption of joint integrity

Splinting techniques plays important role in preserving functional out Splinting techniques plays important role in preserving functional out

come in combination with different treatment availablecome in combination with different treatment available

USES OF SPLINTS IN BURN TREATMENTUSES OF SPLINTS IN BURN TREATMENT

Acute phaseAcute phase

--In acute phase of burn injury, splinting required only when In acute phase of burn injury, splinting required only when

damage of tendons and joints is suspected, splinting will damage of tendons and joints is suspected, splinting will

immobilize, provide support of affected body partsimmobilize, provide support of affected body parts . .

--If it is used, it should be non conforming and non constrictive If it is used, it should be non conforming and non constrictive

securing should be provided due to fluctuation of edema securing should be provided due to fluctuation of edema

during this phaseduring this phase . .

Wound healing phaseWound healing phase

--Splint may prevent development of contracture and Splint may prevent development of contracture and

disruption of newly skin graftdisruption of newly skin graft

--Care must be taken to avoid interfere the splint with healing Care must be taken to avoid interfere the splint with healing

as the result of improper fit or placement as splint has as the result of improper fit or placement as splint has

appropriate length of leverage and edge rolled away appropriate length of leverage and edge rolled away

from skinfrom skin

rehabilitation phaserehabilitation phase

--Splinting is used to reduce contracture non surgically, Splinting is used to reduce contracture non surgically,

prevent deformity, and maintain natural body contoursprevent deformity, and maintain natural body contours

--The combined treatment of splints, exercise, and pressure is The combined treatment of splints, exercise, and pressure is

required; The ongoing process of scar development and required; The ongoing process of scar development and

contracture is managed by maintaining sustained stretch contracture is managed by maintaining sustained stretch

to scar tissue. Exercise may Achieve normal ROM and to scar tissue. Exercise may Achieve normal ROM and

splinting can maintain the range gainedsplinting can maintain the range gained..

Reconstructive phaseReconstructive phase

--Splints applied following the release of contractures or Splints applied following the release of contractures or

reconstructive procedures for restoring function reconstructive procedures for restoring function

and and ..cosmosescosmoses

--Splints are molded directly to the site and should be Splints are molded directly to the site and should be

monitored for evidence of wound maceration or break monitored for evidence of wound maceration or break

downdown..

splinting indicationssplinting indications

Protection of anatomic structuresProtection of anatomic structures

--The goal of early splinting is to stabilize the joints so that all external The goal of early splinting is to stabilize the joints so that all external

forces are eliminated or reducedforces are eliminated or reduced..

--The joint should be splinted in function position as well as the tendon 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 should be splinted in a slack position to prevent rupture of the

tendonstendons..

--Special attention for moisten dressing to exposed tendon to prevent Special attention for moisten dressing to exposed tendon to prevent

drying as well as padding splints to prevent more rupturedrying as well as padding splints to prevent more rupture..

Restore of functionRestore of function

The early non operative resolution of contractures The early non operative resolution of contractures provided by sustained stretch and pressure combine provided by sustained stretch and pressure combine with serial splinting to maintain gained R.O.Mwith serial splinting to maintain gained R.O.M

Splints should be revised to accommodate any Splints should be revised to accommodate any change change in R.O.Min R.O.M..

Requirements for All SplintsRequirements for All Splints

Proper fitProper fit

A splint too loose and without adequate contour will not A splint too loose and without adequate contour will not maintain proper position. A splint too tight will invite maintain proper position. A splint too tight will invite pressure necrosis or nerve compressionpressure necrosis or nerve compression..

Secure applicationSecure application

A splint loosely secured with dressings or straps will A splint loosely secured with dressings or straps will slide, resulting in poor positioning and possible slide, resulting in poor positioning and possible wound maceration. If dressings or straps are too tight, wound maceration. If dressings or straps are too tight, they will restrict vascular flow and encourage they will restrict vascular flow and encourage edemaedema..

Avoidance of pressure over a bony prominenceAvoidance of pressure over a bony prominence

If possible, a splint should not be molded over a bony If possible, a splint should not be molded over a bony prominence. When such application cannot be avoided, prominence. When such application cannot be avoided, construction should avoid direct contact by doming the splint construction should avoid direct contact by doming the splint section over the prominencesection over the prominence

Periodic removalPeriodic removalSplints protecting and positioning an exposed joint or tendon Splints protecting and positioning an exposed joint or tendon should be removed for wound care only. Prolonged static should be removed for wound care only. Prolonged static immobilization can cause joint stiffness, muscle atrophy, or a immobilization can cause joint stiffness, muscle atrophy, or a contracture opposite to the position expectedcontracture opposite to the position expected

Daily checking and re-evaluationDaily checking and re-evaluation

Changes in edema and changes in the bulk or type of dressings Changes in edema and changes in the bulk or type of dressings may require daily splint correction in the early stages of may require daily splint correction in the early stages of treatment. Splint effectiveness also changes as the patient's treatment. Splint effectiveness also changes as the patient's status changes. A careful daily check will help to avoid status changes. A careful daily check will help to avoid splinting problemssplinting problems

Cleansing with each re-applicationCleansing with each re-application

Every time a splint is removed for wound care, exercise or for Every time a splint is removed for wound care, exercise or for any other purpose, it should be properly cleansed with an any other purpose, it should be properly cleansed with an antibacterial agent before re-application in order to prevent antibacterial agent before re-application in order to prevent possible wound possible wound contaminationcontamination

Types of splintsTypes of splints

Usage of Usage of staticstatic or or dynamicdynamic splinting depends upon the splinting depends upon the stage of tissue healing. During the early inflammatory stage of tissue healing. During the early inflammatory stage, static splints are useful, while both dynamic stage, static splints are useful, while both dynamic and serial static splints may be indicated during the and serial static splints may be indicated during the proliferative stage of tissue healing. Although static proliferative stage of tissue healing. Although static and dynamic splints can be beneficial during the stage and dynamic splints can be beneficial during the stage of scar maturation, serial static splints often prove of scar maturation, serial static splints often prove

superiorsuperior . .

Static SplintStatic Splint

--A A static splint supports one or more joints in a specific static splint supports one or more joints in a specific

position for the purpose of immobilizationposition for the purpose of immobilization . .

--A conforming static splint is formed directly on the A conforming static splint is formed directly on the patient in complete contact with the contour of the patient in complete contact with the contour of the

body distribute pressure a long the length of splintsbody distribute pressure a long the length of splints . .

--Non conforming static splint can immobilize the Non conforming static splint can immobilize the extremities but accompanied with pressure problem extremities but accompanied with pressure problem

and slippageand slippage . .

--Thermoplastic material is heated and draped directly on Thermoplastic material is heated and draped directly on the patient, keeping in consideration that the material the patient, keeping in consideration that the material

is safe and comfortable in temperature for patientis safe and comfortable in temperature for patient . .

Dynamic splintDynamic splint

--Dynamic splint applies a specific force in specific plane of motion Dynamic splint applies a specific force in specific plane of motion through elastic tractionthrough elastic traction . .

--It should be considered for these joint demonstrate the most resistance It should be considered for these joint demonstrate the most resistance to passive stretch and don't respond to positioning or to passive stretch and don't respond to positioning or

intermittent stretching techniquesintermittent stretching techniques..

--Prefabricated dynamic splint are used widely in burn rehabilitation, it Prefabricated dynamic splint are used widely in burn rehabilitation, it is available for different body regions, it is worn in the presence of is available for different body regions, it is worn in the presence of

open area, exposed tendonsopen area, exposed tendons . .

--For the best result, dynamic splint can be worn continuously with For the best result, dynamic splint can be worn continuously with gradual increase tension at level where the patient can tolerate , and gradual increase tension at level where the patient can tolerate , and

only removed for short period of time for wound only removed for short period of time for wound carecare . .

Splinting in the Operating RoomSplinting in the Operating Room

--The patient's most painful period is usually prior to grafting, The patient's most painful period is usually prior to grafting, due to exposed nerve endings. If the splint is fabricated due to exposed nerve endings. If the splint is fabricated during partial anesthesia, joints can be during partial anesthesia, joints can be positioned more positioned more

easily and painlesslyeasily and painlessly . .

--Following grafting of deep partial or full thickness burns, Following grafting of deep partial or full thickness burns, immobi lization is essential to prevent displacement or immobi lization is essential to prevent displacement or shearing of the graft while maintaining the graft at its fullest shearing of the graft while maintaining the graft at its fullest excursion. All joints above and below the graft excursion. All joints above and below the graft

should be immobilized until the graft is stableshould be immobilized until the graft is stable . .

--A location adjacent to the operating room should then A location adjacent to the operating room should then be designated and approved for the therapist's use, be designated and approved for the therapist's use,

splinting must be done quickly and efficientlysplinting must be done quickly and efficiently . .

--Needed information, charted by the surgeon, includes Needed information, charted by the surgeon, includes the procedure to be done, the area to be grafted, the the procedure to be done, the area to be grafted, the donor site, and whether the patient will require donor site, and whether the patient will require splints. Using this information, the therapist can then splints. Using this information, the therapist can then determine whether the patient will be prone or supine determine whether the patient will be prone or supine on the operating table, and what type of splints will on the operating table, and what type of splints will

be requiredbe required . .

--As soon as the reversal of anesthesia begins, splint As soon as the reversal of anesthesia begins, splint application should begin. To make the best use of the application should begin. To make the best use of the time before the patient is alert, contour molding can be time before the patient is alert, contour molding can be done in segments and secured with light gauze wrap. done in segments and secured with light gauze wrap. Splints applied in the operating room should be of simple Splints applied in the operating room should be of simple design for rapid molding so as not to extend the design for rapid molding so as not to extend the

operating room or anesthesia timeoperating room or anesthesia time . .

--A small portable water heating source, such as an electric A small portable water heating source, such as an electric skillet, should be set up about a half-hour before skillet, should be set up about a half-hour before splinting time to allow water to reach proper working splinting time to allow water to reach proper working temperature. Splint heating should begin as final temperature. Splint heating should begin as final

dressings are being applied to the patientdressings are being applied to the patient . .

Regional splintsRegional splints

Anterior neck regionAnterior neck region

Anticipated deformityAnticipated deformity: Flexion with possible : Flexion with possible lateral flexionlateral flexion..

Secondary problemsSecondary problems: Disturbance in : Disturbance in mastication; distortion of facial units; difficult mastication; distortion of facial units; difficult or hazardous intubation in subsequent or hazardous intubation in subsequent reconstructive proceduresreconstructive procedures..

Soft cervical collar

(A )Anterior view: )B( Posterior view:Patient wearing soft cervical collar and clavicular strap.

Molded neck splintMolded neck splint

Neck splint custom-made from thermoplastic material

Design and molding halo neck splint on patientDesign and molding halo neck splint on patient

Design and molding halo neck splint on patient

Custom design halo neck splint

Watusi collar made from plastic tubes

Watusi collar made from plastic tubes

Philadelphia collar used for positioning neck

Ear regionEar region

Anticipated deformityAnticipated deformity: folding of helix: folding of helix..

Secondary problemsSecondary problems: auricular chondritis , : auricular chondritis , pressure on damaged earspressure on damaged ears

Semirigid oxygen mask used to protect tissue ofburned ear from pressure.

MouthMouth

Anticipated deformityAnticipated deformity: microstomia, ectropion : microstomia, ectropion of upper and lower eye lidsof upper and lower eye lids..

Secondary problemsSecondary problems: decreased horizontal and : decreased horizontal and vertical excursion , difficult in mastication , vertical excursion , difficult in mastication , and altered speechand altered speech

Microstomia Prevention appliance in place

Microstomia prevention splint fabricated from stainless steel wire, thermoplastic material and rubber band

Acrylic hook used to apply horizontal traction to the mouth via surgical tube attached to neck brace

.

(A )Orthodontic commissure appliance. (B) appliance in place

Shoulder and axillary regionShoulder and axillary region

Anticipated deformityAnticipated deformity: Shoulder adduction, : Shoulder adduction, extension, and internal rotationextension, and internal rotation..

Secondary problemsSecondary problems: Development of kyphosis: Development of kyphosis

Axillary or air plane splint used to position the shoulder in 90 degree

Shoulder abduction brace with forearm platform positions shoulder while leaving axilla exposed

Shoulder abduction brace

Figure of Eight bandage

One type of splint support brace used to correct trunk postural deviation

Elbow and Knee regionElbow and Knee region

Anticipated deformityAnticipated deformity: Flexion with pronation : Flexion with pronation deformitydeformity

Secondary problemsSecondary problems: possible ulnar : possible ulnar compression , possible peroneal compressioncompression , possible peroneal compression

Gutter or trough splint to maintain joint extension

Three point splint for elbow extension

Three point splint for elbow extension , the anticubital fossa remain exposed

Posterior knee extension splint

A type of spiral splint looped around upper extremity to promote elbowextension

Transparent appliance constructed of two layers of plastic that providesimmobilization and compression when inflated

Wrist and Hand regionWrist and Hand region

Anticipated deformityAnticipated deformity: Extension or hyperextension of : Extension or hyperextension of the MCP joints; flexion of the IP joints; boutonniere the MCP joints; flexion of the IP joints; boutonniere deformity; adduction and flexion of the thumb; deformity; adduction and flexion of the thumb; flexion or extension of the wristflexion or extension of the wrist

Secondary problemsSecondary problems: Radial/ulnar deviation; : Radial/ulnar deviation; abduction of the little finger;. flattening ofabduction of the little finger;. flattening of

the palmar arches; finger adduction with syndactyle the palmar arches; finger adduction with syndactyle extension of the IP joint of thumbextension of the IP joint of thumb

Anti deformity hand splint

Wrist splint maintain wrist in extension while the fingers are free to move

Thumb positioned between palmar and radial abduction with a thumb spica splint.

Thermoplastic material conformed along index and the thumb to maintain thumb web space and secured in place by foam straps

(A )Palmar extension splint for right hand .(B )Dorsal extension splint with padding and secured with cohesive wrap

Traction splint post mesh skin graft, finger traction is applied by rubber

bands attached to dress hooks to finger nails and secured to ends of splint

Halo hand splint made from wire outrigger attached to thermoplastic forearm base.

flexion glove assist with finger flexion through elastic traction

( A-)Sandwich splint secured with cohesive wrap to maintain extension of digits

(B -)bivalved sandwich splint to maintain finger in flexion position

dynamic splintdynamic splint HandHand

dynamic splintdynamic splint HandHand

Hip and Perineal regionHip and Perineal region

Anticipated deformityAnticipated deformity: flexion; adduction: flexion; adduction

Secondary problemsSecondary problems: Altered gait pattern; : Altered gait pattern; difficulty with straddle positiondifficulty with straddle position

Anterior hip spica splint made from thermoplastic material to maintain hip extension and abduction while preventing hip flexion and adduction.

Hip :abduction splint made from thermoplastic material secured in place by foam strap

Spreader bar attached to knee gutter splints to maintain abduction

Ankle and Foot regionAnkle and Foot region

Anticipated deformityAnticipated deformity: Dorsiflexion; planter : Dorsiflexion; planter flexionflexion

Secondary problemsSecondary problems: Shortening of Achilles : Shortening of Achilles tendon; equinus deformity: altered gaittendon; equinus deformity: altered gait

patternpattern

Posterior foot drop splint-nonconforming. Heel section cut away to relieve pressure and stand applied to splint to elevate heel off bed

Posterior ankle conformer with heel section flared away for pressure relive, splint secured in place by elastic bandage

.Anterior ankle conformer

High top gym shoe with metatarsal roll-off added to sole of .shoe.

Molded leather shoe with Velcro closure and metatarsal roll-off added to sole of shoe.

Toe conformer splint shaped to cover the dorsal .surface of toes to prevent hyperextension. Can be secured with cohesive Wrap or elastic bandage.