CLINICAL Hand Burns

REVIEW
Indexing Metadata/Description
› Title/condition: Hand Burns
› Synonyms: Thermal injury, partial-thickness burn, superficial thickness burn, superficial
partial thickness burn, deep partial thickness burn, full thickness burn, fourth degree burn,
electrical burn, chemical burn, radiation burn
› Anatomical location/body part affected: Hand; wrist; skin (epidermis, dermis,
subdermal plexus) underlying fascia; muscle, and contractile tissue; bone
› Area(s) of specialty: Acute Care, Wound Management, Hand Therapy, Outpatient
Rehabilitation
› Description
• A burn is an injury to body tissues from exposure to heat, electricity, chemicals, or
radiation(1)
• Burn injuries to the hands and upper extremities account for more than 50% of burn
injuries in North America(3)
• The skin is the largest organ in the body and consists of two layers:(4)
–Epidermis: outermost layer, contains no blood vessels
–Dermis: lies beneath the epidermis and consists of vascular connective tissue that
supports and provides nutrition to the epidermis and skin appendages, which include
hairs, sebaceous glands, sweat glands, and nails
• The severity of burns is classified by the extent and depth of injury, as well as patient
age and associated illness or injury. The extent is the percentage of total body surface
area (TBSA) affected by second- and third-degree burns(12)
–Extent
- The hand represents 3% of TBSA(2)
- The palm of an open hand in an adult is 1% of TBSA(12)
–Depth: the current classification system replaces first-,second-, and third-degree burns
and does not include fourth-degree burns(4)
- Superficial thickness burn: solely affects the epidermis
- Superficial partial thickness burn: affects the epidermis and the superficial dermis and
Authors presents with blisters
Diane Matlick, PT
Cinahl Information Systems, Glendale, CA
- Deep partial thickness burn: affects the epidermis, the deep dermis, and some
Lisa Schulz Slowman, MS, OT/L, CHT
degree of sensory and sweat gland function; presents with less blisters and pain than
Cinahl Information Systems, Glendale, CA superficial partial thickness burns
- Full thickness burn: affects entire epidermal and dermal layers and results in
Reviewer complete loss of skin appendages; are insensate to pain
Andrea Callanen, MPT
- Fourth-degree burn (old classification): affects entire epidermal and dermal layers as
Cinahl Information Systems, Glendale, CA
well as underling muscle, tendon, and bone
Editor
• Although a hand burn only represents a small percentage of TBSA, the functional
Sharon Richman, MSPT impairments that result are significant, and an isolated hand burn is an indication for a
Cinahl Information Systems, Glendale, CA
referral to a burn center for care(5)
› ICD-9 codes
• 944.0 Burn of the wrist(s) and hand(s), unspecified site
January 12, 2018
• 944.1 Burn of a single digit, other than thumb

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or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
 • 944.2 Burn of the thumb
• 944.3 Burn of two or more digits, not including thumb
• 944.4 Burn of two or more digits including thumb
• 944.5 Burn of the palm
• 944.6 Burn of the back of the hand
• 944.7 Burn of the wrist
• 944.8 Burn of multiple sites of wrist(s) and hand(s)
• 948.0 Burn of less than 10% of TBSA
• 949 Burn, unspecified
› ICD-10 codes
• T23 Burn and corrosion of wrist and hand
• T23.0 Burn of unspecified degree of wrist and hand
• T23.1 Burn of first degree of wrist and hand
• T23.2 Burn of second degree of wrist and hand
• T23.3 Burn of third degree of wrist and hand
• T31 Burns classified according to extent of body surface area involved
(ICD codes are provided for the reader’s reference, not for billing purposes)
› G-Codes
• Changing & Maintaining Body Position G-code set
–G8981, Changing & maintaining body position functional limitation, current status, at therapy episode outset and at
reporting intervals
–G8982, Changing & maintaining body position functional limitation, projected goal status, at therapy episode outset, at
reporting intervals, and at discharge or to end reporting
–G8983, Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end
reporting
• Carrying, Moving & Handling Objects G-code set
–G8984, Carrying, moving & handling objects functional limitation, current status, at therapy episode outset and at
reporting intervals
–G8985, Carrying, moving & handling objects functional limitation, projected goal status, at therapy episode outset, at
reporting intervals, and at discharge or to end reporting
–G8986, Carrying, moving & handling objects functional limitation, discharge status, at discharge from therapy or to end
reporting
• Self Care G-code set
–G8987, Self care functional limitation, current status, at therapy episode outset and at reporting intervals
–G8988, Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at
discharge or to end reporting
–G8989, Self care functional limitation, discharge status, at discharge from therapy or to end reporting
• Other PT/OT Primary G-code set
–G8990, Other physical or occupational primary functional limitation, current status, at therapy episode outset and at
reporting intervals
–G8991, Other physical or occupational primary functional limitation, projected goal status, at therapy episode outset, at
reporting intervals, and at discharge or to end reporting
–G8992, Other physical or occupational primary functional limitation, discharge status, at discharge from therapy or to end
reporting
• Other PT/OT Subsequent G-code set
–G8993, Other physical or occupational subsequent functional limitation, current status, at therapy episode outset and at
reporting intervals
–G8994, Other physical or occupational subsequent functional limitation, projected goal status, at therapy episode outset,
at reporting intervals, and at discharge or to end reporting

.
G-code Modifier Impairment Limitation Restriction
CH 0 percent impaired, limited or restricted
CI At least 1 percent but less than 20 percent impaired, limited or
restricted
CJ At least 20 percent but less than 40 percent impaired, limited
or restricted
CK At least 40 percent but less than 60 percent impaired, limited
or restricted
CL At least 60 percent but less than 80 percent impaired, limited
or restricted
CM At least 80 percent but less than 100 percent impaired, limited
or restricted
CN 100 percent impaired, limited or restricted
Source: https://www.cms.gov/

.
› Reimbursement: Reimbursement for therapy will depend on insurance contract coverage; no specific issues or information
regarding reimbursement have been identified for hand burns
› Presentation/signs and symptoms
• Based on classification:(4)
–Superficial thickness burn: erythematous appearance, dry, mildly swollen, blanches with pressure and is painful (e.g.,
sunburn)
–Superficial partial thickness burn: blistering, moist, weeping, blanches with pressure, painful
–Deep partial thickness burn: no blisters, wet or waxy dry, variable color, less painful, at risk for conversion to full
thickness due to marginal blood supply
–Full thickness burn: white waxy to leathery grey to charred black in color, insensate to pain, does not blanch with pressure
• Edema
• Decreased ROM/contractures
–Twenty-three percent of patients hospitalized for a hand burn experience at least 1 contracture, with the wrist joint most
frequently involved(1)
• Hypertrophic scarring(4)
–Hypertrophic scars can result from partial and full thickness burns
–Initially presents as a firm, red area of healed burn scar
–Progresses over weeks to become raised, erythematous, and rigid
• Pain
• Pruritus
• Muscle weakness, atrophy, or destruction
• Status post debridement
• Status post amputation
–For additional information on upper extremity amputation, see Clinical Reviews…Amputation, Upper Extremity, in
Adults: Occupational Therapy; CINAHL Topic ID Number: T708915, and Amputation, Upper Extremity, in Adults:
Physical Therapy; CINAHL Topic ID Number T708916.
• Status post skin graft
• Infection
• Psychosocial issues

Causes, Pathogenesis, & Risk Factors

› Causes
• Most common causes of all burns
–Fire/flame exposure(43%)(4)
–Scalding injuries (36%)(4)
 • Causes that account for the minority of burns(4)
–Electrical exposure
- Flash (arcing), flame, or direct heating by electrical current(12)
–Contact
–Chemical exposure
–Tar
–Radiation
–Grease injuries
–Five percent of burn injuries are the result of child abuse or adult assault or abuse(4)
- Among children under age 2 years, burn injuries represent the leading cause of accidental death, and most of these
deaths are a result of abuse(4)
› Pathogenesis
• The extent of tissue damage is related to the location, duration, and intensity (temperature) of exposure.(4) In the case
of electrical burns, skin damage does not correlate with the degree of injury. Significant subcutaneous damage can be
accompanied by little skin injury, especially in cases when there is larger skin surface area involved due to electrical
contact(12)
• Those at the extremes of age have fewer layers of epithelium, so the same exposure will produce a more serious burn in
older adults and children than in other adults(4)
• Because the dorsum of the hand has relatively thin skin and decreased subcutaneous tissue, it is prone to deep burn
injuries(6)
• After the burn injury, there is a cascade of events(4)
–Initially there is vasoconstriction at the site of the burn injury mediated by the release of norepinephrine and serotonin
–A few hours after injury, vasoconstriction turns to vasodilation, increased capillary permeability, and leakage of plasma
into the extravascular space
–Histamine is released and damaged cells swell
–Fluid shifts result in extravascular edema and intravascular hypovolemia
–Platelets and leukocytes aggregate, leading to thrombotic ischemia
–In severe burn injuries, inflammatory mediators are released and compromise cardiovascular function; burn shock ensues
• Damaged skin loses its ability to act as a protective barrier and homeostatic regulator(4)
–This may lead to loss of body fluids, impaired thermoregulation, and increased susceptibility to infection
- Healing and regeneration(4)
- Because of the destruction of the dermal appendages, spontaneous reepithelialization is impossible with a full
thickness burn injury
- Healing and regeneration in partial thickness burns arise from the epithelial linings of the hair follicles and sweat
glands
- Depending on the depth, epithelialization is completed in 14 to 21 days
- After epithelialization there is continued healing with regeneration of the peripheral nerves (sometimes with
neuropathic pain and itching)
- Dermal scarring occurs on the wound continuously for several months after the injury, and the healing process is
ongoing for 6 months to 2 years, until the skin is mature
› Risk factors
• Male gender(7)
• Most common in males in all age groups except for older adults, among whom burns occur more often in women(26)
• Being a child or an older adult(25)

Overall Contraindications/Precautions
› When possible, burned hands are best treated by a therapist who specializes in burn rehabilitation(5)
› Obtain parental consent before treating minors
› If abuse or neglect is suspected, alert the referring physician and/or appropriate authority
› Patients who have more extensive burns beyond just the hands are at risk for more complicated medical problems (e.g.,
shock)(4)
› See specific Contraindications/precautions to examination and Contraindications/precautions under Assessment/Plan
of Care

Examination
› Contraindications/precautions to examination
• Stop the examination and immediately notify the referring physician if any of the following are present:
–Signs/symptoms of infection(4)
–Deep vein thrombosis (DVT)
–Heterotrophic ossification(4)
–Joint subluxation or dislocation(4)
–Compartment syndrome(4)
- Tends to occur in circumferential burns when the inelastic burned tissue acts as a tourniquet(4)
- Abdominal compartment syndrome is a potentially lethal condition in patients who are severely burned, even if
abdominal decompression is performed. Significant increased abdominal pressure can cause pulmonary damage and
multiorgan system failure. Only 40% of patients will survive(12)
- For more information, see Clinical Review…Compartment Syndrome, Acute: CINAHL Topic ID Number: T708485
–Pneumothorax(12)
–Unremitting pain
• Obtain and follow specific instructions and guidelines from the referring physician and/or surgeon
• As many patients report unbearable levels of pain after burn injury, it is vital to respect the patient’s pain and alert the
physician and/or nurse if the patient’s pain is not being adequately controlled(4)
› History
• History of present illness/injury
–Mechanism of injury or etiology of illness
- How and when did the burn occur?
- How quickly did the patient receive medical attention?
- What classification is the burn?
- If not limited to just the hand(s), where and what % of TBSA?
- Concomitant injuries (e.g., fractures, inhalation injuries, brain injury)?(7)
- Approximately 5% of all trauma patients will also have some degree of burn injury(7)
- If applicable, what has the treatment in the hospital involved up to this point?
- Complications up to this point?
–Course of treatment
- Medical management
- Acute management may include:
- Management of medical complications (e.g., shock, inhalation injury); may involve resuscitation(4)
- Ultrasonic flowmeter: measures digital and palmar pulses. It is the most accurate means of assessing perfusion in the
hands(19)
- Debridement(4)
- Mechanical
- Water immersion
- Water spray
- Wet to dry dressings
- Topical enzymes
- Surgical
- Sequential (tangential)
- Fascial
 - Circumferential fascial
- Escharotomy/fasciotomy
- Indicated for compartment syndrome
- Skin grafting(4)
- Homograft vs. heterograft
- Temporary grafts
- Must be replaced after several days or the immune system rejects them, and it is not common to use
immunosuppressant therapy
- Synthetic wound dressings are also a temporary option until autografting is possible
- Autograft
- Harvested from the patient’s own skin
- Gold standard of treatment
- Split thickness vs. full thickness
- Skin flaps(29)
- May be useful when more coverage is needed
- Groin flaps, as well as preputial flaps (in uncircumcised males), may be utilized to obtain adequate coverage
- Kirschner wire fixation
- Used to immobilize fingers to protect exposed joints and tendons(5)
- Amputation(1)
- May be necessary in burns severe enough that circulation is absent or bone and tissue are destroyed
- Medications for current illness/injury: Determine what medications clinician has prescribed; are they being taken?
- Opioids for procedural pain(5)
- Long-acting analgesics for resting pain(5)
- Short-acting analgesics for breakthrough pain(5)
- Anxiolytics(5)
- Enteral feeding
- Tetanus immunization for all burns deeper than superficial thickness(12)
- Topical antibiotics for all nonsuperficial depth wounds(12)
- Dressings
- Hydrogel
- Low-adherent
- Silver products
- Adhesive
- Negative pressure wound therapy (e.g., wound V.A.C.)(5)
- Diagnostic tests completed: Usual tests for this condition are the following:
- FBC(8)
- Chest X-ray(8)
- Cardiac testing(8)
- Measuring urinary output (may require indwelling catheter)(8)
- Electrodiagnostic testing for peripheral neuropathies(7)
- Approximately 10% of burn patients will develop peripheral neuropathies, most commonly median sensory
neuropathies(7)
- Home remedies/alternative therapies: Document any use of home remedies (e.g., ice or heating pack) or alternative
therapies (e.g., acupuncture) and whether or not they help
- Previous therapy: Document whether patient has had occupational or physical therapy for this or other conditions and
what specific treatments were helpful or not helpful
–Aggravating/easing factors: (and length of time each item is performed before the symptoms come on or are eased): Are
there positions or environments that increase or decrease patient’s pain or itching?
–Body chart: Use body chart to document location and nature of symptoms
–Nature of symptoms: Document nature of symptoms (e.g., constant vs. intermittent, sharp, dull, aching, burning,
numbness, tingling, itching)
–Rating of symptoms: Use a visual analog scale (VAS) or 0–10 scale to assess symptoms at their best, at their worst,
and at the moment (specifically address if pain is present now and how much). For children or nonverbal patients, the
FLACC Scale or Wong-Baker FACES Pain Rating Scale may be used to assess pain(3)
- The Itch Severity Scale is a valid tool for assessing itch severity and the inability to relieve the itching sensation(3)
- Visual Analog Scale for Comfort (VASC): measures perceived level of comfort with a wound dressing(9)
–Pattern of symptoms: Document changes in symptoms throughout the day and night, if any (AM, mid-day,PM, night);
also document changes in symptoms due to weather or other external variables
–Sleep disturbance: Document number of awakenings/night
- As many as 74% of burn survivors reported sleep problems at 1 week after discharge from hospital(4)
- Problems include:(4)
- Nighttime awakenings
- Daytime napping
- Nighttime pain
- Difficulty with sleep onset
- Insomnia and nightmares can persist at 1 year after injury(4)
- Lack of sleep is associated with increased pain complaints the next day, and high levels of pain and analgesic intake
during the day is associated with poor sleep the following night(4)
–Other symptoms: Document other symptoms patient may be experiencing that could exacerbate the condition and/or
symptoms that could be indicative of a need to refer to physician (e.g., dizziness, chills, unremitting pain)
–Respiratory status: Document the patient’s respiratory status, including oxygen use and/or mechanical ventilation
- Inquire about any complications due to inhalation injury, including:(7)
- Pneumonia
- Adult respiratory distress syndrome (ARDS)
- Did the patient require tracheostomy?
–Psychosocial status
- Burn injury survivors are at risk for developing depression, anxiety, and posttraumatic stress disorders(7)
- The largest prospective cohort study found that significant psychological distress is common and tends to persist for at
least 2 years after burn injury(7)
- Depression can have a negative impact on recovery(7)
- Risk factors for depression include premorbid psychiatric problems, head or neck burns, increased length of hospital
stay, and female gender(4)
- Post-traumatic stress disorder (PTSD)(4)
- According to one study, 21% of subjects at 1 month and 19% at 1 year met full criteria for PTSD
- Symptoms of PTSD tend to decrease over time (although there are no validated treatment interventions) and it is
common for burn survivors to display some symptoms of PTSD but not fulfill diagnostic criteria
- Over half of burn survivors report posttraumatic stress symptoms at 1 day, 1 month, and 1 year after injury
- Alteration in body image affecting one’s self-esteemis one of the most devastating consequences of a burn injury(7)
- Individuals with altered body image report social functioning as a major source of difficulty and distress(7)
- The ultimate goal of rehabilitation is normal reintegration into the community
- In a study utilizing the Community Integration Questionnaire, researchers found significant problems in home
integration, social integration, and productivity(4)
- There may be some common themes experienced by patients following hand burns(28)
- The results of a qualitative research study conducted in South Africa found common themes expressed by the burn
survivors in the areas of burn experience, therapy experience, and social issues
- Burn experience themes included acknowledgement of the traumatic aspects of the incident, the “psychological maze”,
“changing faces of pain”, and the functional challenges and impairments faced by the survivors
 - Therapy themes included the feeling that therapy makes a difference and an understanding of the sequelae that lead to
disability that can occur without therapy intervention
- Social issues identified included the stigma attached to the burn, a need for support (from family and friends), as well
as an acknowledgement of personal growth that occurred following the injury and confidence for facing the future
–Barriers to learning
- Are there any barriers to learning? Yes __ No __
- If Yes, describe ____________________________
• Medical history
–Past medical history
- Previous history of same/similar diagnosis
- Is there a prior history of burn(s)? Prior history of any dysfunction involving the affected hand(s)?
- Comorbid diagnoses: Ask the patient about other problems, including diabetes, cancer, heart disease, complications of
pregnancy, psychiatric disorders, orthopedic disorders, etc.
- Medications previously prescribed: Obtain a comprehensive list of medications prescribed and/or being taken
(including over-the-counter drugs)
- Other symptoms: Ask the patient about other symptoms he or she may be experiencing
• Social/occupational history
–Patient's goals: Document what the patient hopes to accomplish with therapy and in general
–Vocation/avocation and associated repetitive behaviors, if any: What does the patient’s job require? Is the patient
involved in any sports or recreational activities? Does the patient attend school?
–Functional limitations/assistance with ADLs/adaptive equipment: Did the patient have any prior functional limitations
or require any assistance with ADLs? Does the patient have any adaptive equipment? Which is the patient’s dominant
hand?
–Living environment: With whom does the patient live and who are the patient’s caregivers? Are there stairs in the home?
Number of floors? Identify if there are barriers to independence in the home; any modifications necessary?
› Relevant tests and measures: While tests and measures are listed in alphabetical order, sequencing should be appropriate to
patient medical condition, functional status, and setting
• Arousal, attention, cognition (including memory, problem solving): Assess orientation; more in-depth testing is indicated
if brain injury or other cognitive impairment is present. Utilize such measures as Mini-Mental State Examination (MMSE),
and obtain testing done by other disciplines if possible
• Assistive and adaptive devices: Assess fit of current devices, including orthoses/splints, ADL devices, and ambulatory
devices. Are they appropriate? Are they being used properly? Are other devices indicated? Does the current state of the
patient’s hand(s) affect his or her ability to use assistive and ambulatory devices properly?
• Balance: Assess static and dynamic balance as indicated
• Cardiorespiratory function and endurance: Monitor vitals throughout evaluation and treatment, including oxygen
saturation if indicated
• Circulation: Assess pulses and capillary refill time(3)
–Vascular compression and insufficiency and compartment syndrome are characterized by loss of or weakened pulses,
decreased capillary refill time, deep tissue pain, and paresthesia(3)
• Cranial/peripheral nerve integrity: Assess integrity of peripheral nerves as indicated; the median and ulnar nerves are
most often involved in neuropathy(2)
• Edema: Measure edema using circumferential or figure of eight measurements, or using water displacement (volumetric
measurements)(3)
• Ergonomics/body mechanics: Observe for proper body mechanics during functional movements; ergonomic assessment
may be indicated for return to work and ADLs
• Functional mobility (including transfers, etc.): Assess functional mobility utilizing such objective measures as the FIM,
WeeFIM (for children),(3) and Timed Up and Go (TUG) test. Mobility may be affected by the patient’s decreased ability to
use hand(s)
• Gait/locomotion: Assess gait as indicated. Observe for abnormalities and assess safety with objective measure such as
Dynamic Gait Index (DGI)
• Joint integrity and mobility: Joint subluxations are common after hand burn injury, most commonly in the
metacarpophalangeal (MCP) joints(4)
 –Common deformities: web space contractures; fifth finger abduction deformity; MCP joint extension deformities;
boutonniere, swan neck, and mallet deformities; and palmar cupping(2)
• Motor function (motor control/tone/learning): Assess coordination, fine and gross dexterity of the hand, and functional use
of the hand. Utilize such objective measures as:(3)
–Jebsen-Taylor Hand Function Test
–Nine Hole Peg Test
• Muscle strength: Assess strength of entire affected upper extremity as indicated; when appropriate, assess hand strength
utilizing hand dynamometry and pinchmeter(3)
• Neuromotor development: Assess as appropriate for children who haven’t yet met developmental milestones
• Observation/inspection/palpation (including skin assessment)
–Scar assessment
- Modified Vancouver Scar Scale
- Scores a scar in four domains: pliability, height, vascularity, and pigmentation(7)
- Scar pliability can be measured with a Cutometer(7)
- Pigmentation can be measured with a Mexameter(7)
- The Matching Assessment with Photographs of Scars (MAPS) scale assigns a score of 1–4 based on description photos
for scar height, thickness, and color and texture of the scar surface(3)
- Changes in scar adherence and tightness are charted and/or photographed(3)
- Are there any hand deformities developing?
- A debilitating and difficult to treat deformity is the claw hand (wrist flexion, MCP joint hyperextension, and IP joint
flexion)(27)
- Other common deformities include adduction contracture of the thumb and web space contractures (i.e., burn
syndactyly)(27)
–Are there exposed tendons?(10)
–Is there hypertrophic scarring? Hypertrophic scars are raised, red, painful, pruritic, and contractile(7)
- Hypertrophic scarring is the most common complication of burn injury(7)
- Risk factors for hypertrophic scarring are wounds that had a prolonged inflammatory healing phase and wounds that
were open for longer than 3 weeks(7)
–Inspect for signs and symptoms of infection, DVT, and chronic regional pain syndrome (CRPS) (e.g., trophic changes)
• Palpation: Palpate the texture of the scar; assess for pain on palpation
• Perception (e.g., visual field, spatial relations): Assess as indicated
• Posture: Assess as indicated
• Range of motion
–Assess using a goniometer and/or composite linear measurements, including distance from the tip of the finger to the
distal palmar crease during finger flexion and the distance between the tip of the finger and a level surface during full
finger extension.(3) Can also utilize:
- Kapandji Thumb Opposition Scale(3)
- Measurement of abducted hand span(3)
- Overlay tracings of the hand(3)
–Contractures
- Most commonly wrist extension and flexion, digit metacarpophalangeal (MP) flexion, and index finger proximal
interphalangeal (PIP) flexion(2)
- TAM: Sum of ROM of all the fingers and the thumb that can be compared over the course of treatment(9)
- Burn contractures are graded based on whether they are supple and reducible or rigid and fixed, and what is the severity
of ROM limitation(3)
• Reflex testing: Assess as indicated
 • Self-care/activities of daily living (objective testing): Assess ability to perform ADLs and self-care activities (e.g.,
bathing, brushing teeth) that are very likely affected by decreased hand use. Utilize objective measures such as the Barthel
Index
• Sensory testing: Perform thorough sensory testing of affected areas, including vibration threshold, temperature and texture
discrimination, touch threshold discrimination using two-point discrimination and Semmes-WeinsteinMonofilaments(3)
• Special tests specific to diagnosis
–Disabilities of the Arm, Shoulder and Hand (DASH) Outcome Measure(3)
- For additional information on the DASH, see Clinical Review…Disabilities of the Arm, Shoulder and Hand (DASH)
Outcome Measure, CINAHL Topic ID Number: T903177
–Michigan Hand Outcomes Questionnaire (MHQ)(3)
–SF-36(3)
–Burn-Specific Health Scale-Brief (BSHS-B)(3)
–Active Research Arm Test (ARAT)(9)
–Visual Analog Scale for Function (VASF): measures the patient’s perceived level of function while in a wound dressing(9)

Assessment/Plan of Care
› Contraindications/precautions
• Always follow physician and/or surgeon orders for treatment
• The involved extremity should be positioned above the heart to minimize edema unless otherwise instructed(19)
• Utilize sterile techniques for all wound care
• If any part of the extensor mechanism in the hand is disrupted, flexion of multiple joints (i.e., composite flexion), for
example making a fist, is contraindicated(2)
• Patients with this diagnosis may be at risk for falls; follow facility protocols for fall prevention and post fall prevention
instructions at bedside, if inpatient. Ensure that patient and family/caregivers are aware of the potential for falls and
educated about fall prevention strategies. Discharge criteria should include independence with fall prevention strategies
• Clinicians should follow the guidelines of their clinic/hospital and what is ordered by the patient’s physician. The summary
below is meant to serve as a guide, not to replace orders from a physician or a clinic’s specific protocols
• Only those contraindications/precautions applicable to this diagnosis are mentioned below, including with regards to
modalities. Rehabilitation professionals should always use their professional judgment
–Transcutaneous electrical nerve stimulation (TENS) contraindications (11)
- Presence of a cardiac demand pacemaker
- Stimulation across chest
- Malignancies in the area to be treated
- Uncontrolled seizure disorder
–TENS precautions(11)
- Altered or absent sensation
- Pregnancy
- Protruding metal (e.g., surgical staples, external fixation) or metal implants
- Incision – stimulation should not put stress on an incision
- Allergic reactions to electrodes or conduction medium, skin irritation
–Therapeutic ultrasound contraindications(11)
- In an area with infection or bleeding
- If a tumor is present in the area
- In the area of DVT or thrombophlebitis
- Over epiphyseal plates of growing bones
–Therapeutic ultrasound precautions(11)
- Use caution if patient has circulatory impairments
- Use caution in patients with sensory deficits and in patients who are unable to communicate sensory deficits
- Use caution over plastic or metal implants
- Always decrease ultrasound intensity if the patient complains of discomfort
 –Thermotherapy contraindications(11)
- Decreased sensation
- Decreased circulation/Vascular insufficiency
- Recent or potential hemorrhage
- Malignancy
- Acute inflammation
- Infection
- Where heat rubs or liniments have recently been used
- In patients with cognitive deficits or if a language barrier exists
› Diagnosis/need for treatment: Patients with hand burns require rehabilitation to improve edema, wound healing, ROM,
strength, coordination/dexterity, and overall function and to prevent secondary complications such as contractures and
hypertrophic scarring
› Rule out: N/A
› Prognosis
• The first 48 hours of burn care offers the greatest impact on the morbidity and mortality of a burn victim. Early surgical
intervention, wound care, enteral feeding, glucose control, metabolic management, infection control, and prevention of
hypothermia and compartment syndrome all contribute to significantly lowering mortality rates and hospital length of
stay(12)
• Prognosis will depend upon several factors including the extent and location of tissue damage, any associated injuries
as well as comorbidities and complications. Complications impacting prognosis include: sepsis; gangrene (with limb
amputation); cardiac, neurologic, cognitive, or psychiatric impairments(12)
• The typical healing time: superficial burns reported to range between 3 and 10 days, superficial partial thickness burns ~
2weeks, and deep partial thickness burn ≥ 3 weeks(25)
• A study in Australia found that patients with isolated hand burns that were able to be treated conservatively or with
biosynthetic skin substitutes healed quicker than those that required excision and skin grafting(13)
• According to a study in India, burns with contractures considered severe with biopsy and electrophysiological studies may
not achieve full functional recovery(14)
› Referral to other disciplines
• Surgeon
• Physician
• Pain management specialist
• Nursing for wound care needs
• Occupational therapy for ADL training, orthotic fabrication
• Psychologist or psychiatrist for depression, anxiety, or PTSD-relatedsymptoms
• Physical therapy for gait training
• Social services for home needs
• Support group
• Speech/swallowing therapist if indicated
• Nutrition/dietary if indicated
• Appropriate authority if abuse or neglect is suspected
› Other considerations
• A randomized controlled trial in Egypt found that for deep second and third-degree hand burns, early excision and skin
grafting with physiotherapy gave better results than delayed grafting for preservation of hand function and length of
hospital stay(6)
• Compared to burns in other regions, hand burns can be more difficult for graft fixation due to the curved and mobile
surface area, which increases the risk for cicatricial contracture(20)
• Music therapy can reduce pain and anxiety associated with dressing changes based on a small randomized crossover trial
conducted in the United States(22)
–Twenty-nine patients were randomized to music-based imagery before and after dressing changes and active music
making during dressing changes compared to those without music therapy, and then crossed over to alternate treatment on
the second day
 –Compared to the control group, music therapy was associated with reduced pain before, during, and after dressing
changes, reduced anxiety and muscle tension during dressing changes, and reduced muscle tension after dressing change
› Treatment summary: There is no consensus regarding treatment of hand burns across the spectrum of severity because
there is a lack of controlled comparative treatment studies(5)
• Typical treatment includes:(2)
–Edema management
–Splinting to prevent contractures and deformities
- Acutely, usually with a classic volar positioning splint (VPS)
- Splint is removed for ROM and wound care
- Generally, a hand that is healing without complications does not have to be positioned in an orthosis unless there is a
limitation in AROM of the metacarpophalangeal (MCP) and interphalangeal(IP) joints of > 20° in extension or MCP or
IP joint flexion is < 70°
- Serial casting should be used to gain extension if there is < 20 of IP joint extension
- For outpatients, can utilize flexion gloves, a palmar conformer, an ulnar gutter, finger gutter, or casting (usually reserved
for children)
- Therapists need to continually check for proper fit of the orthosis and make any necessary changes. Changes in the bulk
bandages will alter the fit of the orthosis(24)
- Children can tolerate longer immobilization than adults because of the elasticity in their joints. It is important not to
over-immobilize the joints, which can result in joint stiffness, contractures, and soft tissue adhesions. As ROM and level
of arousal improve, patients should increase their active participation with exercises and functional mobility(24)
–PROM and then AROM exercises
- Exercises are performed to help preserve joint ROM, ensure tendon gliding, and help maintain oblique and transverse
retinacular ligament length(24)
- If the extensor mechanism is disrupted, ROM should be performed using the tendon glide technique, mobilizing a single
joint while maintaining the others in extension
- Combined flexion must be avoided as it could rupture the fragile extensor mechanism
- If the burn is full thickness, the extensor mechanism in the hand is likely affected(2)
- When ROM exercises are being performed at the IP joint, the MCP joint and the wrist should be positioned in extension
to put the tendon at maximum slack(24)
–Scar management and prevention/management of hypertrophic scarring(4)
- Risk factors for hypertrophic scarring based on a systematic review of 48 articles are female gender, young age, dark
skin, burn site on neck and upper limb, meshed skin graft, multiple surgical procedures, increased time to healing, and
severity of burn(23)
- Scar compression (e.g., elastomer web spacers) may be helpful to decrease deformity or to maintain positioning after a
contracture release(27)
–Strengthening exercises
–Functional activities
• The exercise regimen and choice of orthotic intervention for exposed and ruptured tendons before grafting vary depending
on the extent and location of the tendon exposure and the apparent integrity of the tendon and surrounding tissue(24)
–If the tendon appears healthy and exposure is small, aggressive ROM may be ordered(24)
• A randomized crossover study in the United Kingdom compared Gore-Texbags with traditional dressings (nonadherent
dressing followed by gauze and bandages) in 30 healthy volunteers(9)
–Outcome measures included TAM, Kapandji scale, ARAT, VASC, VASF, sensation
–The Gore-Tex bag dressings were found to allow for better ROM, 1stcarpometacarpal (CMC) joint motion and sensation
–Traditional dressings were found to have better perceived comfort
–No significant differences were found in function and perceived function
• A study in Japan assessed the efficacy of a surgical glove following graft procedures(20)
–Six patients with hand and digital burns in Japan had undergone full thickness skin grafts that were secured by a surgical
glove dressing. All grafts fully took and none of the patients developed infection, hematoma, or joint contracture
 –Researchers concluded that their surgical glove provides the graft with appropriate tension and circumferential pressure
using a simplified and cost-effective technique(20)
• A case study in the United States found that 3M Coban Self-Adherentwraps effectively reduced edema in a patient status
post skin grafting, and the reduced edema resulted in improved ROM, strength, and function compared to the other hand
(control), and the dressing did not impede hand mobility, grip strength, and function(15)
• A study of 19 patients with hand burns (30 hands) in Poland found a rehabilitation program to be effective during the
hospitalization period(16)
–The program included edema reduction techniques, ROM exercises, and encouraging patients to use the injured hand in
everyday activities
• A small case study in the United States involving 3 patients found noncontact low-frequency ultrasound may help stimulate
the healing process and alleviate pain in burn wounds(17)
• A case study in the United Kingdom found that the technology-basedwound dressing Mepitel One effectively controlled
exudate, allowing for alternate day dressing changes. The dressing was easily removed, which reduced trauma to newly
healing skin on the hand and decreased subjective complaints of pain(21)
• A randomized controlled trial in Egypt found that playful activity based on playing and games improved hand function and
movement better than rote exercise(18)

.
Problem Goal Intervention Expected Progression Home Program
Pain and pruritus Decreased pain and Patient education Reduced pain and Educate family and
pruritus _ itching over time caregivers as to
Encourage compliance the importance of
with prescribed compliance
medications and
creams/lotions
_
_
Electrotherapeutic
modalities
_
Some success has
been reported with
TENS use for pain and
pruritus(5)
_
_
Alternative treatments
_
Additional studies
are needed to prove
effectiveness of:
distraction techniques,
virtual reality, music
therapy, and massage(5)
Unhealed wound Completely healed Prescription, N/A Educate family and
_ wound without application of devices _ caregivers.
_ complications and equipment _ _
Edema _ _ Reduced edema over Educate patient, family,
_ _ Application of time or caregivers in home
_ Decreased edema dressings prescribed by _ management
Scar complications _ physician _ _
_ _ _ N/A _
_ Well-healed scar _ _ _
Contractures, decreased with minimized Patient education _ Educate patient, family,
ROM, deformities complications (such as Encourage protection Improved ROM over and caregivers on self-
_ hypertrophic scarring) of healing wounds at all time management
_ _ times _ _
Decreased functional _ _ _ _
use of hand(s) Improved ROM, _ Improved functional Provide patient and/or
prevention or resolution Prescription, use of hand(s) over family and caregivers
of contractures, application of devices time leading to on home program to
prevention of and equipment full community improve ROM and
deformities Pressure garments, reintegration prevent contractures
_ wound dressings, _
_ splinting(5) _
Improved functional _ _
use of hands for return Elevation above the Provide patient with
to ADLs, self-care, heart avoiding wrist exercises to perform at
work, school, and flexion, which can home
recreational activities block lymphatic
_
drainage(5)
Increase strength for
_
functional and age-
_
appropriate activities
Manual therapy
_
Manual mobilization,
including the web
space, isolated tendon
gliding, manual
lymphatic drainage(5,24)
_
_
Therapeutic exercise
_
PROM and AROM
exercises and
strengthening
exercises(5,24)
_
_
_
Exercises should be
performed a minimum
of three times a day
and consist of exercises
to achieve full PROM
and AROM of the
digits, wrist, and upper
extremity(24)
_
 _
Electrotherapeutic
modalities
_
Paraffin at 120° can
moisturize but does not
increase ROM alone.(2)
Moisturizing before
stretch can decrease the
risk of skin tears during
stretching(2)
_
_
Functional training
_
Strengthening
exercises, functional
mobility training,
dexterity, and
coordination activities;
activity-specific
training; sensory
reeducation or
desensitization(3)
_
_
_
Refer to occupational
therapy

Desired Outcomes/Outcome Measures

› Decreased pruritus
› Community reintegration
› Decreased pain
• VAS
• Itch Severity Scale
• VASC
› Decreased edema
• Circumferential measurements/volumetric measurements
› Improved strength
• MMT/hand dynamometer/pinchmeter
› Improved range of motion
• Goniometric measurements
• TAM
• Kapandji Thumb Opposition Scale
› Improved functional mobility
• FIM/WeeFIM
› Return to ADLs, self-care, work, and/or recreational and school activities
• Barthel Index
› Improved fine motor skills
• Jebsen-Taylor Hand Function Test
 • Nine Hole Peg Test
› Non hypertrophic healed scar
• Vancouver Scar Scale
• MAPS scale
› Normal sensation
• Sensory testing
› Improved functional upper extremity use
• DASH Outcomes Measure
• MHQ
› Improved quality of life
• SF-36
• BSHS-B
• Community Integration Questionnaire
• VASF

Maintenance or Prevention
› Assist the patient and family with school and work reentry. If the patient is school-aged, the patient may require a school
assessment to determine if an individualized education plan (IEP) is needed. If the patient is returning to work, a functional
capacity exam may be required
› Burn prevention counseling during routine pediatric well-visits(25)
› Sun protection is essential for burn survivors(4)
› Educate families about the potential household hazards and prevention of burns(8)
• Safety in the workplace
• Safety in the home, including regular maintenance of smoke alarms and temperature of hot water heater
–Test bathwater and supervise children during bath time; cook on rear burners when children are present
• Prevention of electrical burns (e.g., replace frayed cords)
• Sunburn prevention
• Appropriate supervision of small children – keep matches, lighters, and chemicals out of reach of children, fireplace safety

Patient Education
› Mayo Clinic Website offers burn information and can be accessed at:
https://www.mayoclinic.org/diseases-conditions/burns/symptoms-causes/syc-20370539
› The Phoenix Society for Burn Survivors provides numerous resources for burn survivors and can be accessed at:
https://www.phoenix-society.org/
› Information and programs for social skills training can be found at: https://www.changingfaces.org.uk/

Note
› Recent review of the literature has found no updated research evidence on this topic since previous publication on June 3,
2016

Coding Matrix
References are rated using the following codes, listed in order of strength:

M Published meta-analysis RV Published review of the literature PP Policies, procedures, protocols

SR Published systematic or integrative literature review
RCT Published research (randomized controlled trial)
R Published research (not randomized controlled trial)
C Case histories, case studies
G Published guidelines
RU Published research utilization report
QI Published quality improvement report
L Legislation
PGR Published government report
PFR Published funded report
X Practice exemplars, stories, opinions
GI General or background information/texts/reports
U Unpublished research, reviews, poster presentations or
other such materials
CP Conference proceedings, abstracts, presentation

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