Jayden Lee

CONDITION CHART: Burn 3rd Degree Skin Graft

OT In…
Condition:
3rd Degree Burns: Burn injuries can be caused from a lot of things, like contact with flame,
scalding steam, grease, prolonged contact with something hot, and chemicals. It can also occur
from electrocution or an explosive blast 10. 3rd degree burns, or full thickness burns, penetrate
through the epidermis, dermis and hypodermis layers of the skin. Nerves are often destroyed and
thus sensation in this area is impaired. Therefore, these burns are often slow to heal and may not
hurt. The burn may appear to be white, grey, black, brown, yellow, charred, waxy or leathery5.

Skin Graft: 3rd degree burns do not heal properly on their own and so surgery is required to
perform a skin graft10. A skin graft is usually a piece of skin that is unburned from the victim's
body (besides their face) and is removed from its original spot and then covered over the burned
area. The area where the piece of unburned skin was taken from is called the donor site and the
burned areas that are being treated is called the recipient site12. There are many different types of
options for skin grafts. Some instances call for using animal skin or synthetic tissue to use for the
graft. Some grafts do not use every layer of skin. For Third degree burns, a full thickness graft
which uses every layer of skin from the donor is typically used6. After surgery, clients typically
require two weeks to heal with minimal movement. Before and after a skin graft, there is risk for
contracture because when the skin is burned, the surrounding skin begins to pull together9, 14.
This is of concern because if the scar from the contracture crosses a joint, it can limit the range of
motion at that joint.4, 13. There is also concern of increased/decreased sensation at the recipient
site after a skin graft9.

Scenario: Client is a 40 y.o female who is a chef at a local restaurant . While cooking a meal on
the stove on 4/20/2021, the client was cooking over an open flame and some of the cooking oil
ignited the flame more and she came into contact with the fire. This prolonged thermal and flame
exposure caused her to suffer 3rd degree burns on her R dorsal hand, wrist and distal forearm.
The burn is yellow, waxy and leathery. She fell on her dominant hand which affects her ability to
cook at the level she was prior, write, and do most ADLs efficiently. She also cannot feel
anything in her hand due to nerve damage and therefore it is unsafe to cook/work at the
restaurant considering that there is a risk of hurting herself again from steam, fire, hot surfaces
and sharp utensils. The burn did not heal properly on its own so she received a full thickness skin
graft on 05/01/2021 and the donor site is from her inner thigh. It should heal in a few weeks post-
op but for the first 3 to 5 days but she is supposed to keep it still and apply no pressure to it.
After those first 3-5 days, the graft is usually incorporated into the wound and thus mobilization
and therapy can begin1. Because of the location they recommend she does Outpatient OT so that
the scar tissue doesn’t shorten and limit her ROM. Wound healing is in three phases and she can
begin with therapy in the 3rd phase which is the maturation phase14.
Jayden Lee

Posture: Normal (line/segment) Static /Dynamic Movement

static/dynamic picture/description

Standard Posture Whole: In regards to

standard anatomical posture,
there is proper alignment that
allows less strain and stress
on the body. In this lateral
view pictured to the right,
there is a plumb line drawn
that forms the axis of
reference. It runs through the
ear, the shoulder, lateral
elbow, posterior hip, anterior
knee and lateral malleolus.
These are all bony landmarks
that fall within the plumb
line2.

Part: the hand

There are important
landmarks for ideal hand
alignment at rest. for the
hand as well. They include
nail position, space between
the index finger and the Plumb line, lateral view2
thumb, cascading flexion of
the fingers and the size of the
thenar eminence, and
prominence of the ulnar
head. Slight wrist extension,
composite flexed posture.11

Position of comfort after a

burn is typically shoulder
adduction and internal
rotation, elbow flexion, wrist
extension and MCP
extension/neutral position
Jayden Lee

Hand Position at rest11

A) Radial pronated view
B) Neutral palmar view
C) Ulnar pronated view

Client Factor (Body Faults/Imbalance Local Description: Radiocarpal and

Part) Limitations MCP joints
Due to condition and
resulting skeletal
imbalance

Wound contraction Due to the dorsal hand burn, Joint specific: radiocarpal joint and
occurs during the the extrinsic and intrinsic MCP joint
wound healing phase. extensor muscles on the hand
The ultimate tensile will be tight. The flexor Muscles that cross the wrist that
strength regained to muscles of the forearm that are shortened and tight due to
the wound is 80%11 cross the wrist and MCP immobilized kinematic chain14:
Scar contraction can joint will be weak. Extensor carpi radialis longus,
lead to loss of extensor carpi radialis brevis and
functional mobility. Radiocarpal joint and MCP longus, extensor carpi ulnaris,
As long as scars are joint scar contracture could extensor digiti minimi, extensor
active, they are more lead to a loss of functional digitorum. Abductor pollicis longus,
likely to respond to joint mobility and adaptive extensor pollicis brevis, extensor
Jayden Lee

therapy10,11 Stronger shortening. Therefore all of pollicis longus, extensor indicis

muscles are better able the following movements Intrinsic hand muscles: lumbricals
to move against could potentially be affected: mm., dorsal interossei muscles mm.
tightening scars. wrist extension, wrist
Exercise promotes flexion, adduction and
strength, dexterity, abduction
coordination, and hand MCP: flexion, extension,
function11. adduction, abduction,
circumduction, and limited
rotation.

Image: b is a full thickness 8

skin graft post op5

Functional Kinematics Detail

Movement
Affected/Compensato
ry

Descriptive: Expected Explanation: why the pattern

Jayden Lee

kinematic change evolved/occured

Limited use of affected hand, Clients are hesitant to use their

rely on non-dominant hand
Like detailed above, If
limited wrist movement,
compensatory movements
would be
Shoulder elevation
elbow internal rotation
affected hand because they are afraid
of pain, pressure, blisters or injury14.
Limited ROM may also be present
after skin graft.
Postural changes: Wrist extension and
MCP extension at rest due to adaptive
shortening and contracture

Proximal joint: Wrist extension

stiffness/loss of ROM due to joint
contracture, adaptive shortening and
immobilization post surgery
Distal joints: MCP extension
stiffness/loss of Rom due to
contracture

Occupations Affected OTPF (generally and specific Activity Task Specific

to the scenario) Client-Centered Detailed

The client’s General concerns Activities That are affected by a

occupation will be Stabilizes: Holding onto
affected in many ways. items while keeping wrist in
She cooks as a trade extension will be challenging
which is greatly for my client. This can affect
affected. occupations such as holding
onto a frying pan, holding
wrist for writing
appropriately and pulling on
clothes to put on her body.
Grasping and
manipulating: these motor
skills will be affected due to
the affect posture of the wrist
and some of the thumb
movements. It will make it
hard to grip cooking and
writing utensils as well as
3rd degree burn skin graft
Cooking: (more specific, cooking
food in a frying pan):
Overall sensory issues are a safety
concern when cooking.
Lifts: pan from cabinet to stove is
difficult because of the weak flexion
of the wrist and the MCP joints
Manipulates: manipulates the
ingredients, spatula, and turns on the
stove. Grasping is difficult with
affected hand
Coordinates: both hands are needed
to work together to stir and hold the
handle of the pan which can be
difficult.
Jayden Lee

dressing in general. Grasps: Client has to hold onto the

Lifting: for the same reasons handle with her hand. Due to joint
above, wrist contracture may contracture and adaptive shortening,
hinder the posture of the grasp is greatly affected.
hand and therefore make it Stabilizes: holds plate still when
more difficult to lift things. transferring food from pan to plate
Writing:
Work: Client cannot work Stabilizes: compensating by holds
and cook as she used to. paper with helper hand that is not
affected by burn
Leisure: client enjoyed Grasping: holding writing utensil
cooking in her free time as with affected hand. This is difficult
well, but also cannot play because having an appropriate grasp
with her nieces and nephews is difficult due to pain, contracture,
like she is used too. She shortening and weakness.
cannot lift them or do arts Manipulating: rotates pencil in hand
and crafts with them because to use eraser is challenging because
of her limited mobility, isolated finger movements are
minimized strength and difficult due to weakness of the flexor
stiffness from her skin graft. digitorum muscles.
Calibrates: uses appropriate speed
ADLs: decreased abilities and force when writing with the
due to compensating with ehr affected hand. Sensory issues make
non-dominant hand this difficult, as well as weakness and
limited ROM.
IADLs: laundry is Dressing:
challenging because she Stabilizes: Holding onto the clothes
cannot grasp the handles on while actively dressing. This is
the laundry basket with both challenging with her affected hand.
hands, and it is often too Coordinates: doing a combination of
heavy movements to put on a clothing item.
Grasping: holding onto pants while
Sleep/Rest: Client tends to pulling them up or holding onto a
sleep on her right side. She shirt while pulling it down. This is
must be mindful of her hand difficult for similar reasons
and not apply too much mentioned above for grasping in the
pressure on it at night. She writing and cooking description.
reports many nights spent
restless and awake.
Jayden Lee

Assessment Evidence

Types of Assessments: ● Impairment: Rom Support, Explanation, Location

● Impairment testing for wrist and ● ROM test is to see if joint
based metacarpals contracture occurs at the
Assessments ● Performance test: 9 wrist, CMC joint, and MCP
● Performance hole peg test joint.
● SROM ● Special test sensory: ● 9 hole peg test is used to test
● Special Tests Froment’s sign finger dexterity. 3RD degree
● SROM: Patient burns can cause joint
specific functional contracture and affect the
scale finger muscles so it is
important to test for
impairments.
● Froment's sign: test for
sensory deficits that can
happen due to the third degree
burn. This test specifically
looks at ulnar nerve deficits
● Patient Specific Functional
Scale allows the patient to
describe occupations that are
specifically important to them
and allows us to have
objective measures and
benchmarks to refer to during
treatment.

Therapeutic Biomechanical/Remediate Occupation-based

Interventions

Goal: To restore Sensory reducation7: touch OBI:

proper posture at rest, discrimination. Touch the
gain back functional patient with light force at the Cooking:
ROM at the recipient site and have them Pt will practice frying an egg
Radiocarpal joint and decipher whether it was to increase fine/gross motor skills.
the wrist joint, stretch static touch or moving touch. For safety reasons, we will do this
out the extensors of Then do straight to curved using a toy egg and not with the stove
the wrist and hand and line discrimination. Do this turned on. We will also wear a glove
strengthen the flexors 12 times a day for 15 for protection and emphasize safety
of the hand and distal seconds. This is to address precautions throughout.
Jayden Lee

forearm. sensory concerns that occur

after third degree burns
Nadelec
Stretching: extensors
Wrist Extensor Stretch11:
Hold the arm with elbow in
neutral position and palm
facing down of the affected
hand. Push downward on the
back of the affected hand
until a stretch is felt in the
muscles on the forearm.
Hold for 10 seconds and the
rest. Repeat 3 times.
Finger MP extension
stretch3: Move each finger
away from the palm of your
hand, straightening the base
of your finger, and apply a
gentle stretch. Hold each
stretch for about 5 seconds
and repeat for about 5
stretches. This will stretch
the extensors at the MCP
joint
Pt will crack 2 eggs, dispose of the
egg shells, pour eggs into a pan, hold
the handle of the pan and cook eggs
thoroughly. Pt will then transfer the
egg back to the plate
Dressing:
Buttoning and zipping clothes
Take 1 shirt with bigger buttons to
start with and practice button and
unbuttoning the buttons. If the client
can do this then grade up with a shirt
with smaller and more buttons. If
necessary, the client can add a key
chain circle and string to zipper to
provide something larger to hold on
to and control for calibration.

Strengthening: Flexors
Thera-band rollers:
Client will start with both
hands on the roller and will
rotate one hand toward the
body and one hand away. Do
this 10 times and rest, and
then repeat for 3 sets.

Wrist Flexion strength with

dumbbell15: Hold the
dumbbell in hand, rest the
wrist over edge of table, flex
Jayden Lee

the wrist up toward ceiling,

perform multiple repetitions
in a controlled manner,
perform 3 sets of 8
repetitions to fatigue. This
allows the client to
strengthen the wrist flexor
muscles for stability and
performance.
Jayden Lee

References

1. Browning, J. A., & Cindass, R. (2020). Burn Debridement, Grafting, and Reconstruction.

PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK551717/

2. Demott, L. (2021). Functional Anatomy [Carmen].

3. Finger MP Flexion Stretching. (2021). Physiou.health; Physio•U.

https://app.physiou.health/app/ex_patt/p66/

4. Healthwise Staff. (2020, July). Skin Grafts: What to Expect at Home (A. Husney MD, M.

Gabica MD, & E. Roh MD, Eds.). Myhealth.alberta.ca.

https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?

hwid=zc2700

5. Kubota, Y., Mitsukawa, N., Chuma, K., Akita, S., Sasahara, Y., Rikihisa, N., & Satoh, K.

(2016). Hyperpigmentation after surgery for a deep dermal burn of the dorsum of the

hand: partial-thickness debridement followed by medium split-thickness skin grafting vs

full-thickness debridement followed by thick split-thickness skin grafting. Burns &

trauma, 4.

6. Morales-Brown, L. (2021, February 16). Third degree burns: Causes, symptoms, and

treatment (A. Biggers, M.D. MPH, Ed.). Www.medicalnewstoday.com.

https://www.medicalnewstoday.com/articles/third-degree-burns#treatment

7. Nedelec, B., Calva, V., Chouinard, A., Couture, M.-A., Godbout, E., de Oliveira, A., &

LaSalle, L. (2016). Somatosensory Rehabilitation for Neuropathic Pain in Burn

Survivors. Journal of Burn Care & Research, 37(1), e37–e46.

https://doi.org/10.1097/bcr.0000000000000321
Jayden Lee

8. Payne, R. M., Quiroga, L., Cooney, C. M., & Caffrey, J. A. (2018). Use of vascular clips

to approximate skin grafts on the burned hand. Burns Open, 2(3), 126-129.

9. Rectors and Visitors of UVA. (n.d.). Skin Graft | UVA Health. Uvahealth.com; EBSCO’S

Health Library. https://uvahealth.com/services/plastic-surgery/skin-graft

10. Simko, L. (2018). Understanding a Burn Injury | Model Systems Knowledge Translation

Center (MSKTC). Msktc.org.

https://msktc.org/burn/factsheets/Understanding_Burn_Injury

11. Sports Medicine at Mass General Hospital. (n.d.). Wrist and Elbow Strengthening and

Stretching Exercises. In Massgeneral.org. Retrieved July 30, 2021, from

https://www.massgeneral.org/assets/MGH/pdf/orthopaedics/sports-medicine/physical-

therapy/mass-general-wrist-and-elbow-strengthening-exercises.pdf

12. Treatments for Third-Degree Burn in Children | Boston Children’s Hospital. (n.d.).

Www.childrenshospital.org; Boston Children’s Hospital. Retrieved July 29, 2021, from

https://www.childrenshospital.org/conditions-and-treatments/conditions/t/third-degree-

burn/treatments

13. UPMC orthopaedic Care. (n.d.). Muscle Contracture and Stiffening Symptoms | UPMC.

UPMC Orthopaedic Care. https://www.upmc.com/services/orthopaedics/conditions-

treatments/contractures-and-stiffness#overview

14. Wietlisbach, C. M. (2020). COOPER’S FUNDAMENTALS OF HAND THERAPY :

clinical reasoning and treatment guidelines for common... diagnoses of the upper

extremity. (3rd ed.). Mosby.

15. Wrist Flexion Strength with Dumbbell. (2021). Physiou.health; Physio•U.

https://app.physiou.health/app/ortho/p1873/