Outcomes of therapy management of palmar burn injuries in young children

Palmar burn injuries are common in young children. Significant functional consequences may result due to loss of range of motion (ROM) associated with scarring across the flexor surface of the hand. This thesis aims to build upon current knowledge of therapy management of palmar burns in young children (aged <5 years). Five studies were undertaken to explore assessment techniques and examine outcomes of early and intensive splinting of isolated palmar burn injuries in young children. 

Chapter 1 is a literature review, which includes therapy assessment of palmar burns, the role of splinting to maintain ROM, and current outcomes of palmar burns in young children. Chapter 2 (Study 1) describes outcomes of current splinting practice of palmar burns at the Children’s Hospital at Westmead (CHW). This retrospective review of 107 children aged less than four years, found 3% palmar contracture up to two years following burn in children using a palm and digit extension splint (mean use 280 days), suggesting this could be a useful intervention. However, limitations in objective measurement of palmar ROM were identified. Consequently, an assessment technique utilising linear hand measures was developed and its reliability explored in Chapter 3 (Study 2). Excellent intra-rater and inter-rater reliability was established for the between-hand difference in hand span and hand length. The mean normative between-hand difference in hand span and hand length was determined (2 millimetres [mm]), as well as the cut-off for the normative difference in hand span (<9mm) and hand length (<6mm). Chapter 4 (Study 3) built further upon therapy assessment and explored palmar scar prediction using cutaneous functional units (CFUs). Good to excellent inter-rater reliability, validity, and predictive validity of face-to-face and photographic scar prediction according to 29 palmar CFUs was established. 

Chapter 5 (Study 4) presents the first study to prospectively describe splinting outcomes following palmar burn in young children (n=75). Children were splinted for mean 264 days following burn. Scar, ROM, developmental and quality of life outcomes were assessed up to 9-18 months following burn. Early signs of contracture (ESC) developed in 14 hands (17%). Two hands (3%) progressed to contracture. Burns involving more CFUs, or more palm or first webspace CFUs were significantly associated with ESC and contracture. Chapter 6 (Study 5) qualitatively explores the parent perspective of implementing the splinting regime. Parents perceived the impact of splinting to be greater on them than their child. They described the importance of routine and therapeutic relationships in their ongoing engagement with intervention. Overall, parents perceived burden of care manageable considering outcomes achieved. 

Chapter 7 summarises the main findings of the thesis, discusses clinical implications and future research opportunities. In summary, studies within this thesis contribute to knowledge of therapy management of palmar burn injuries in young children. A technique to measure palmar ROM and determine contracture has been provided and reliability of palmar scar prediction according to CFUs has been established. These findings informed methodology in the prospective study where use of a palm and digit extension splint demonstrated excellent ROM outcomes at scar maturation.