Managing Care: A Team Approach Helps Burn Patients with Amputations to Heal
July 2012 Issue
According to the American Burn Association (ABA), approximately 450,000 people in the United States sought medical treatment for burn injuries in 2011. Of the three classifications of burns-thermal, chemical, and radiation-thermal burns (such as a scalding) are the most common type of burn for which children are treated, according to Shriners Hospitals for Children- Tampa, Florida. For adults, the most common type of burn injury occurs from fire, according to the ABA, which also reports that burns are considered the leading cause of accidental injury and death worldwide.
Although the majority of burn injuries are not life threatening- most people requiring medical attention for a burn are treated and released-a small percentage of burn victims are burned badly enough that their injuries result in complex medical complications ranging from significant skin issues to the development of contractures to the amputation of one or more limbs. Whether providing prosthetic care to amputee patients with burn injuries or to patients whose amputations are the result of a burn injury, a proactive approach within a team environment is the best method for helping these patients heal, says Pamela Gibson, CPO, LPO, area practice manager for Hanger Clinic, Galveston, Texas. "Individuals who have had amputations due to a burn-related injury often have many issues that have to be addressed, and their prosthetic care is just part of what they're dealing with," she says. "Having the support of a team of professionals involved lets us focus on what we do best and provides resources for us and the family as the individual progresses through the rehabilitation process."
Robert Loeffler, CPO, agrees. As a clinician in the orthotics and prosthetics department at Shriners Hospitals-Springfield, Massachusetts, he treats children who are referred to him from Shriners Hospitals-Boston, Massachusetts, a 30-bed pediatric burn hospital. "The best approach for a burn amputee patient is a coordinated one, which includes input from a number of medical professionals, from the attending physician, nurses, physical and occupational therapy [to] prosthetics," he says.
Jim Rogers, CPO, FAAOP, senior clinician at Pinnacle Orthotics & Prosthetics, Chattanooga, Tennessee, has more than 32 years of experience in the evaluation, design, and fabrication of orthotic and prosthetic devices. His burn experience began at Shriners-Boston, while he worked at Boston Children's Hospital. He also advocates for a multidisciplinary approach.
"Burn patients often undergo many surgeries, and not only can this affect prosthetic fittings, but it can also cause tissue swelling and require periods of post-operative immobilization," he says. A team that includes plastic surgeons, wound care nurses, and occupational and physical therapists is the minimum for coordinated care, according to Rogers. "It also helps that every member of the team is saying the same thing to the patient because the rehabilitative course is long and arduous, and patient expectations need to be managed and kept realistic," he says.
That rehabilitation process can often be the proverbial long and winding road, filled with peaks and valleys. "The physical and mental condition of the patient needs to monitored," Loeffler advises. "A disfiguring event like a burn can take months or sometimes years to heal to a point where a patient can deal with it emotionally...."
Loeffler sees pediatric burn patients from the United States and abroad, saying that "overseas patients generally involve electrical burns. Developing countries don't provide the same safeguards for potential hazards that the United States does."
During his years working in a burn unit, Rogers says the primary causes of amputation he saw in the adult population were from necrotic tissue and infection caused by the loss of the body's protective later-the skin. "If you have exposed tissue over a large portion of a lower extremity and there are not enough donor sites to provide adequate coverage, amputation may be necessary to prevent systemic infection from endangering a patient's life," says Rogers, who has also provided O&P care at the Vanderbilt Burn Center, Nashville, Tennessee, and the Burn Unit at Erlanger Medical Center, Chattanooga. Erlanger closed its Burn Unit in 2008.
A Defining Moment
Amputations due to burns are some of the most challenging and heartwrenching fittings done by prosthetists; however, most clinicians will go the length of their careers without having to treat a patient with burn-related injuries.
"Unless your practice is located near a burn hospital, you won't see that many [burn] patients. It's a very small patient population; most prosthetists may see a burn patient once in their career," says Dan Morgan, CP, who is semi-retired and lives near San Antonio, Texas. He has more than 30 years of experience working with pediatric burn patients at Shriners Hospitals for Children-Galveston. "It can be pretty grisly looking. Many of them have been burned all over their body," Morgan says. "You take one look at them and say to yourself, 'are the things that I normally do going to work?'"
Fortunately, most burn care occurs at a regional burn center, and the prosthetists and orthotists in those areas often become quite experienced at treating patients with burns, Rogers says. "Prosthetists and orthotists in areas not served by a burn center may see a patient post burn, but it is usually long after the acute injury and rehab are completed," he says. Receiving early prosthetic care at a burn center benefits the patient in the long run, Rogers says. "Then when they return home to their local prosthetists and orthotists, they can participate in their care in a meaningful way."
The fragile nature of skin remaining on the residual limb creates a "tremendous challenge" for the prosthetist, especially if the patient is active, Rogers says. "It is unfortunate that sometimes our technology combined with limitations of a short or severely scarred residual limb may conspire to limit the functional capacity of an otherwise active amputee."
O&P professionals who have spent most of their careers helping patients with burn injuries can readily recall when they encountered and treated their first badly burned patient.
For Don Cummings, CP, director of prosthetics at the Texas Scottish Rite Hospital for Children (TSRHC), Dallas, it was the boy who ended up with bilateral transfemoral amputations after surviving a house fire.
"He eventually did extremely well with his prostheses. He had a lot of drive and a great attitude, which made all the difference," says Cummings, who has worked at TSRHC since 1987. "He helped me to have patience when it comes to healing time and readiness for prostheses."
For Gibson, whose Hanger Clinic works closely with a local burn hospital that refers its amputee burn patients to them, it was an eight-year-old boy from Mexico who had sustained a severe burn from an electrical injury that resulted in the loss of both arms and a leg. "He was so distraught, even though the team was working diligently to get him up and moving," Gibson says. "He told me that he wished he could figure out how to throw himself out of bed and kill himself. I almost fell apart when he told me this."
Fortunately, Gibson was able to locate another patient of a similar age and with similar amputation levels who was willing to do a peer visit. The peer visit seemed to change everything for her young patient. That was six years ago. Today, the boy is an ambulatory teenager who can independently perform activities of daily living (ADL) and goes to school. "Fitting this young man has been difficult due to his short residual limbs and his extensive scar tissue," Gibson says. "But he is such a pleasure to work with, and he has been an inspiration to us all."
Loeffler remembers one of his patients, a college student who had received a scholarship to play goalie for her school's soccer team. She was burned in an auto accident, and, as a result of her injuries, she became a bilateral transtibial amputee and had to give up the game she loved.
Ingrid Parry, MS, PT, has worked in burn care for 17 years and currently holds a dual appointment as a rehabilitation research therapist and a burn rehabilitation specialist at Shriners Hospitals for Children- Northern California, Sacramento. She remembers a case involving two brothers working on a ranch in rural Mexico. They were returning home from a day's work when one of the brothers stepped on electrical wires buried just below the dirt. When his brother tried to pull him off the wires, he, too, was burned- so badly that he had to have a leg amputated, Parry recalls.
"It is amazing what the body can handle," Parry says.
Rogers remembers working with one young man who was severely burned in a car accident and had burns over more than 90 percent of his hands and arms. The resulting scars and skin grafts were causing contractures in multiple planes, and he had lost several digits and a thumb, Rogers remembers. "The challenge was trying to fashion orthoses that provided improved grasp while protecting his skin," he says.
A Unique Set of Challenges
Before a prosthetic fitting can happen, function, skin integrity, strength, range of motion (ROM), state of mind, and family and social issues that may influence the fitting have to be evaluated, Cummings says, especially when it comes to children. "The process of healing physically and emotionally can take years," he says.
Loeffler says at his facility in Massachusetts, Child Life Services gets involved from "day one." "These folks are trained for dealing with specific issues individually," he says. "No two patients are necessarily alike, and no two responses to an event like a burn are alike."
The challenges of treating such a patient population aren't just physical, Gibson agrees. "The psychological aspects of these injuries can be overwhelming...to deal with, and strong family support is essential," she says.
When fitting a burn patient with an orthosis or a prosthesis on the affected area, the first concern has to be maintaining the skin's integrity, Rogers says. In pediatric patients, the growth of scar tissue does not always keep up with the growth of the bony anatomy and can result in the need for multiple revision surgeries, according to Gibson. Also, the scar tissue can cause contractures that have to continuously be addressed through aggressive physical therapy, including splinting and stretching the skin, as well as multiple surgeries, Parry adds.
"After a serious burn, it is often necessary to minimize the surgical intervention to save a person's life and reduce stress on the body," Rogers says. "This may not result in the best residual limb for prosthetic use."
Scar or graft breakdown is the most common complication that Rogers encounters among burn patients, followed by the bony prominences that result from poor tissue coverage. Scarred or grafted skin is less elastic and often irregular in its surface texture, and any shear forces occurring between the skin and interface can quickly cause breakdown. "So reducing shear forces is important," Rogers says. Another concern is transferring weight bearing forces, if possible, to more tolerant tissue, which often requires creativity and experience, Rogers says.
From Loeffler's perspective, skin tissue damage and stabilizing tissues to prevent unwanted sores or breakdown are the primary concerns. "Usually by the time a patient gets to me, the condition of the skin has improved to the point of a well-healed scar," he says. "My job is to fabricate a prosthetic device that improves the daily function of my patient and not be a continuous source of concern."
Fittings for complex and multi-focal burn injuries remain an imperfect science, Cummings adds, and patience is paramount. "It may require...multiple fittings before the ideal prosthetic solution is found," he says.
Rogers agrees. "Most prosthetists have had one or two patients that present a fitting challenge that causes them to deviate from their norms and simply fit diagnostic socket after diagnostic socket until the right combination of function and comfort is found that facilitates the desired and expected activity level," he says.
"Don't get in a hurry," Cummings says. "Focus on protecting skin grafts, adherent or thickened scars, insensate areas, and all injured tissue from further trauma."
Of course, a good socket fit is paramount, he adds. Any movement between the residuum and the socket must be eliminated or reduced as much as possible. This often means that gel liners, locking pins, and vacuum systems are indicated, he says.
Parry lectures on burn care and rehabilitation at three major universities and has mentored numerous students in her previous role at Shriners. She has presented multiple abstracts at national and international conferences and published articles in the area of burn rehabilitation, including "Effects of Skin Grafting on Successful Prosthetic Use in Children with Lower Extremity Amputation" (Journal of Burn Care & Research, November/December 2008, Vol. 29, Issue 6). For the study, a retrospective chart analysis was performed on 45 pediatric patients who underwent lower-limb amputation between 1997 and 2006. Patients were divided into two groups. Members of the first group had skin grafts on their residual limb(s), and members of the second group had no skin grafts on their residual limb(s). The study concluded that the presence of skin grafts on a child's amputated limb(s) does not adversely affect functional outcome and does not lead to greater prosthetic complications. However, children with skin grafts were fitted with their prostheses significantly later than patients without skin grafts. Parry's group continues to study this population to determine prosthesis wearing patterns and gait efficiency.
Improvements to Care
Overall, care for burn patients with one or more amputations has improved, particularly over the last ten to 15 years, our experts agree. "One of the main changes we've seen is the vast variety of interface materials we now have available to us," Gibson says. "We're no longer intimidated by fabricating a prosthesis for a residual limb that is completely covered with scar tissue or skin grafts. Being able to provide carbon-fiber feet that are lightweight and dynamic allows for us to design a prosthesis that helps aid in shear absorption within the socket."
Cummings agrees. Compared to 15 years ago or so, there are now more socket designs, materials, components, suspension systems, gel socks, and gel liners available than ever before to help prosthetists problem-solve and custom design a prosthesis to meet their patient's needs, he says.
According for Loeffler, improvements in the skin/socket interface have evolved, and today the use of a roll-on gel-type liner that reduces friction and often supplies nutrients such as vitamin E to the affected site are the standard of care.
Another step forward in care for this population includes early prevention of contractures, Gibson says. "We also work with a group of plastic surgeons who are continually working on advanced techniques for scar-tissue releases to assist with the prevention of these contractures," she says.
Orthotists should play an integral role in contracture management, but not every orthotist is comfortable with this role, Rogers says. "Managing soft-tissue deformities is of prime importance to function," he says. "Limbs with limited range of motion have limited function. Reversing contractures before orthotic treatment is a good idea if maximum outcomes are desired."
Concentric torsion joints allow the orthotist to fabricate orthoses that are total contact and maintain the corrective forces below the shear limits of the scarred tissue or the stretch reflex of the underlying connective tissue, Rogers says. "These joints make successful contracture management in this population a reality compared with treatment regimens of 20 years ago."
Healing, Inside and Outside
The experts interviewed for this article agree that in addition to quality care and support from healthcare professionals, a strong, positive attitude- on the part of the patient and the family alike-goes a long way toward recovery.
"I'm not sure if children have a harder time than adults dealing with this type of injury. From a social aspect, adults have more difficulty dealing with the physical appearance of burn scarring than do children. I know I would," Loeffler says. "Children, especially younger ones, have not had the social exposure that adults have had, so perhaps appearances are not as critical."
Dealing with pain, however, is much harder for children, but because of the physical nature of young versus old skin, children tend to heal faster, according to Loeffler.
A child's recovery differs greatly from an adult's, Gibson says. Working in a team environment that includes the family and the school, if possible, has a big impact, she says.
Cummings says each adult and child is different. "Children with amputations have the advantages of being smaller, lighter, healing faster, and possessing the resilience of youth," he says.
The soccer player that Loeffler treated is a good example. There was a lot of family care and support involved in her recovery, he says. "A variety of outcome expectations were voiced. Some realistic, others not."
After multiple prosthesis designs and a lot of [physical] therapy, this particular patient has become a story to share, Loeffler says. "Although her days as a soccer goalie are over, she has found success in other ways," he says. "Currently, she travels as a spokesperson for limb-deficient athletes."