The American Burn Association reports approximately 450 000 burn injuries each year in the United States. Burn survivors often benefit from direct therapeutic intervention to facilitate functional recovery; however, even with aggressive therapy they remain at a high risk for development of joint limiting hypertrophic scars (HTSs) during scar maturation. Scar maturation is a prolonged process that may persist for 1 to 2 years following a burn or traumatic injury.1 Areas that experience prolonged healing (>21 days) are at a higher risk for the development of HTS. Young age, skin color (darker skin in particular), and meshed skin grafts are considered risk factors for HTS development.2,3
HTSs are found in as many as 32% to 72% of burn survivors3 and if left untreated can cause pain, debilitating loss of range of motion, and loss of functional independence.4–6 These inelastic, thick masses of dense tissue develop from an overproduction of collagen fibers during wound healing7 and cause changes in the makeup and elasticity of the skin.
In lower extremity burns, HTSs that develop at the joints are especially problematic and can result in gait deviations and compensatory movements during gross motor (GM) skills. In these cases, escalation of therapy services and multimodal treatment options may be required to maximize outcomes and optimize quality of life.
Contractures resulting from HTSs are historically difficult to remediate and often require invasive surgical releases or further grafting procedures. Current noninvasive methods of treatment include compression garments (CGs), splinting, and the use of insert materials such as silicone, elastomers, and neoprene to provide pressure, encourage hydration, and regulate temperature at the scar location.8–11 The best method to treat troublesome HTS may be a combination of therapies including stretching, massage, splinting, inserts, and application of compression,12–15 but no standard of care for combination therapy has been described in the literature.
The purpose of this case study is to present the details of the multimodal therapeutic interventions used to successfully treat a child with a foot and ankle joint-limiting HTS contracture.
This case describes a 6-year-old girl who sustained deep partial-thickness burns from a hot water scald. These bilateral burns extended from her distal toes to approximately 5 inches proximal to her ankles, sparing the plantar surface of her feet. Her injury required a 3-day hospital admission during which she received physical therapy (PT), focused on increasing active ankle range of motion (ROM), increasing left step length, improving erect posture, increasing heel strike bilaterally, and decreasing right foot supination in stance. She was discharged with a home exercise program (HEP), with emphasis on increasing active ankle ROM and ambulation with normal gait pattern.
At 3 weeks postdischarge, she continued to have nonhealing wounds. At that time, she underwent autografting of dorsal feet and lower legs for definitive wound closure. Two weeks following grafting, she was fitted with interim CG followed by custom CG 6 weeks after wound closure. Scar maturation and further CG needs were monitored at regular burn clinic follow-up appointments.
At her burn clinic visit 4.5 months after burn injury, she was observed to have active and passive ROM deficits at her left ankle and toes when walking barefoot. She had no left ankle plantar flexion (PF) beyond neutral and, at rest, had 20° of metatarsophalangeal (MTP) hyperextension at all toes. These limitations were difficult to observe when she was wearing shoes and had not been noticed by her family. Upon examination, HTS contractures were observed at her left dorsal ankle and foot over her second and third MTP joints. She had a small (1.5 cm × 0.5 cm) nonhealing area at her left dorsal foot distal to her ankle crease, which appeared dry with no exudate. The area was located within the HTS, in an area covered by CG and was being treated with antibiotic cream. No measurable edema was present in her distal extremity.
In an attempt to decrease the thickness and rigidity of the HTS and improve ROM, the medical team performed intralesional steroid injections at 5 months postgrafting. Despite reported daily compliance with HEP and custom CG, she continued to have aggressive formation of HTS and progressive functional limitations. A referral was made to outpatient PT for intervention 2 times per week.
The family reported 2 primary goals for their child: (1) left toes to contact the surface when standing and during activities and (2) left ankle wound to heal and remain closed.
Examination. During her initial outpatient PT evaluation, assessment was performed using goniometric measures and clinical observation of bilateral ankles and feet at rest, during functional movements, and with gait.
In sitting and standing, the less affected right ankle was observed to be in neutral position with full floor contact of foot and 5 toes. Right MTP joints were in a neutral position. The affected left ankle was observed to be in neutral position with full floor contact of foot and great toe. The second through fifth MTP joints were in extension with no floor contact of toes. The third MTP joint was noted to rest in the most extension followed by the second MTP joint and less at the fourth and fifth MTP joints (Figure 1A).
Initial passive (pROM) goniometric measurements were ankle dorsiflexion (DF) ROM of 0° to 21° on left and 0° to 20° on right and ankle PF ROM of 0° to 10° on left and 0° to 45° on right. During pROM of left ankle into PF, pain was reported as 2/10 pain on the Wong-Baker FACES scale.16 Despite the relatively low pain score, she reported that this pain prevented further PF.
During ambulation with shoes on, she had a slight decrease in left ankle PF during toe-off phase compared with the right; however, there were no other noticeable gait deviations. When ambulating barefoot, there were noticeable increased gait sequencing deficits at her left ankle and foot, including a lack of floor contact of the second through fifth toes during both mid-stance and toe-off and decreased ankle PF during toe-off.
Minimal to no deficits were observed during age-appropriate GM skills (skipping, jumping, galloping, and running) with shoes on. However, barefoot she demonstrated more limiting deficits (decreased left ankle PF, no toe contact during take-off and decreased weight shift forward onto forefoot) on left compared with right. She demonstrated increased lateral trunk sway and decreased balance during single-leg stance times on left. Her right ankle was observed to have more ankle PF at take-off position during all skills with higher heel position compared with left. She demonstrated compensatory movements with shoes on by decreasing her right ankle PF at take-off.
During static and dynamic balance activities, she had decreased ankle strategies on left with increased compensatory movements (increased use of hip and stepping strategies to remain balanced). Poor toe contact on the left contributed to her decreased balance and compensatory movements.
A HTS was present along the outer edges of the grafted dorsum of bilateral feet. The left foot HTS extended from the dorsum of her foot onto the second and third toes, drawing the toes into an extended position at MTP joints and a flexed position at proximal interphalangeal joints. On palpation, the scar was banded demonstrating increased blanching with ankle PF stretch and at attempted flexion of second and third digits at the MTP joints. The HTS quickly became hypervascular when not in CG. The previously described open, dry area of the HTS was present.
The Vancouver Scar Scale (VSS)17 is a 0- to 15-point scale to assess scar characteristics of pliability, height, pigmentation, and vascularity and was chosen to numerically assess the left foot HTS. A higher number on the VSS indicates a more aggressive scar. Studies have shown the VSS to have a good correlation coefficient interrater reliability (0.81)17 and a Cohen's K statistic of 0.5 ±0.1 between observers, which is 5 standard errors beyond chance and statistically significant.18 The scale can be performed on assessment and at subsequent visits to evaluate progress.
At initial presentation, VSS scores were 12/15 at the dorsal ankle, 12/15 at the dorsum of the foot, and 13/15 at the dorsal MTP and toes. Based on the VSS rating, both the dorsal ankle scar and dorsal foot scars were described as contracted (permanent shortening of scar, producing deformity or distortion), more than 1 to 2 mm in height, red, and hyperpigmented. The dorsal MTP and toe scar was described as contracted, more than 2 to 4 mm in height, red, and hyperpigmented.
Functional limitations and the aggressive nature of the scar indicated a need for PT services 2 times per week. Each session included manual soft tissue mobilization and scar massage, ROM and stretching, jumping, running, tandem walking, and patient and family education that included stretching, scar management, and GM skills. Continued CG wear of 23 hours per day and daily HEP were recommended.
Description of Interventions
After 2 weeks of consistent PT attendance and home program completion (5.5 months postinjury), the multijoint-limiting HTS continued to worsen at the left ankle and toes. Although this initial therapeutic intervention resulted in a 5 ° improvement in ankle PF to 0° to 15°, the poor pliability of the HTS resulted in increasing deformity at the toes. At rest, toes 2 to 5 were now 1.5 to 2.0 cm from contact with the floor. These deficits were present throughout static standing, gait, and higher level functional and GM activities.
The treating PT consulted with burn team members, including an occupational therapist experienced in burn scar management. Interdisciplinary assessment suggested that this patient's young age, short length of time since initial injury, and high VSS scores made her an excellent candidate for combination therapy to improve her HTS. A multimodal treatment plan was developed to aggressively treat this multijoint HTS and to facilitate improved ROM and functional movements.
Expected outcomes were ROM at left ankle within 5° to 10 ° of right ankle ROM and measurable improvement of scar by the VSS and wound closure. It was also expected that she would show improvements with gait, GM skills, and balance activities by achieving full floor contact with toes.
Scar Modalities and Splinting
A multimodal scar treatment strategy was developed in conjunction with continuation of the outpatient PT plan of care. Otoform elastomer (Dreve Otoplastik, Unna, Germany) and thermoplastic splinting (EZEFORM, Rolyan Patterson Medical, Bolingbrook, Illinois) were selected for their ability to concurrently provide compression, encourage hydration, and stretch the scar. A custom Otoform elastomer wedge, including web space inserts, was molded to cover both scars of the left foot and ankle. A thermoplastic ankle PF splint was then fabricated over the Otoform wedge (Figure 2).
Wear Schedule and Progression
The Otoform wedge and splint were worn at night without the CG. The CG only was worn during daytime hours.
As ROM improved, the modalities were altered to continue to provide static progressive stretching to the scar band. Following 1 week of wear after a 23° PF improvement, the thermoplastic splint was remolded. After 2 weeks, significant improvement in toe flexion and ankle PF necessitated fabrication of a new Otoform wedge and thermoplastic splint modification.
The PF gains plateaued 1 month after beginning Otoform and splint wear. Wear schedule was decreased to every other night. When not wearing splint and Otoform, she was to wear her custom CG with a neoprene insert to continue remodeling the scar. Following this splint wear change, she initially experienced mild regression (5°) of left ankle PF ROM. Lost ROM was regained within 1 week of continued alternated wear schedule.
After 2 months of wear, a new Otoform wedge was fabricated due to daily wear causing breakdown of the wedge material. At PT discharge (12 weeks postevaluation), she was instructed to decrease splint and Otoform wear from every other night to every third night with a goal to be fully weaned from wear in 2 weeks. She continued to be seen at regular intervals (3-6 months) through the burn clinic for CG needs and to monitor for regression of scar. CG and neoprene use were to be continued until the scar was mature, as determined by the burn physician (see the supplemental table, Supplemental Digital Content 1, available at: http://links.lww.com/PPT/A126).
As with any pediatric burn injury and HTS, future physical development must also be taken into consideration. As she grows, changes in the HTS and ROM losses may develop, which could require further therapy or medical interventions. She will continue to be monitored for many years through the burn clinic.
Description of Outcomes
Improvements were measured following 12 weeks of direct therapeutic interventions in conjunction with modalities.
In sitting and standing, her left and right ankles were resting in neutral position with full floor contact of hind and forefoot; all 5 toes and MTP joints were in neutral position (Figure 1B). Goniometric measures at discharge were as follows: left ankle DF, 0° to 21°; right ankle DF, 0° to 20°; left ankle PF, 0° to 50°; and right ankle PF, 0° to 45°. She reported no pain with ROM. Compared with initial evaluation, she demonstrated an initial gain of 5° PF ROM prior to addition of Otoform and splinting and an overall gain of 35° at discharge.
There were no gait deviations of the left foot and ankle as compared with right. She had full floor contact with all 5 toes during mid-stance at toe-off and full functional left ankle PF during toe-off phase of gait sequence.
During age-appropriate GM skills, no observable deficits were present. She had decreased lateral trunk sway and improved balance during stance phases on left with increased left ankle PF at take-off with a more equal heel position bilaterally. During static and dynamic balance activities, she demonstrated appropriate ankle strategies bilaterally with return to full toe contact on left. She had no compensatory hip and/or stepping strategies as compared with initial evaluation and required no assist.
There were HTS improvements in pliability, height, vascularity, and pigmentation. There were improvements in VSS scores: ankle, 6/15; toes, 7/15; and dorsum of foot, 7/15. With this scar improvement, her wound was able to fully heal with only use of antibiotic ointment.
Family goals set at initial evaluation were met during the course of multimodal treatment. Full toe contact on left with gait, stance, and functional activities as well as full wound closure at left ankle with no recurrence was accomplished.
HTSs are functionally limiting, cosmetically unappealing and can be very painful. Direct therapy services, including stretching, gait retraining, scar massage, and compression garments are essential components of maximal recovery following a large burn injury. Occasionally, these methods alone are not sufficient.
In the case presented, the child's multijoint limiting contracture was treated using a combination of 3 separate interventions: direct therapy intervention with CG, insert materials, and splinting. By using a custom-molded Otoform wedge in conjunction with static progressive, thermoplastic splinting to address toe and ankle joints concurrently, rapid and lasting gains in ROM and scar pliability were achieved. These gains were maintained through the use of neoprene inserts and CG to facilitate remodeling of the remaining hypertrophic tissue.
The described treatment was well tolerated, easily carried out by this family and can be replicated with common therapy materials. She reached full passive PF and toe contact 4.5 weeks after beginning modalities, sooner than would be projected without the use of scar management modalities. Through the 12 weeks of therapeutic intervention, she was able to achieve her personal goals of wound closure and full toe contact with the surface at rest, and she was able to regain normal pain-free functional movement.
No standardized protocol exists for this multimodal approach. The treating therapist should adjust and remold static progressive splint and elastomer modalities as HTS and ROM improve. For this case, remolding occurred at 1 week, 2 weeks, and 2 months.
Although it is impossible to predict the severity of HTS development, the early initiation of a multimodal approach could be considered in any case with higher risk factors for HTS. Insert materials are valuable additions to scar treatment and CG and should be used as soon as potentially joint limiting scars are identified. It is expected that earlier addition of modalities may have decreased the severity of HTS in this case.
Replication of this treatment may be limited by resources available and the patient's access to therapy services. This treatment may be less effective with more mature HTS. Patient compliance is essential to attaining desired results. The compliance of the family must also be addressed, and consistent patient and caregiver education is necessary to achieve maximal gains, especially when multiple modalities are being used.
For burn survivors with HTS, the therapist should consider multimodal methods of treatment, beyond ROM, stretching, massage, and CG. When adjunct modalities are included in the treatment plan for an active scar, a patient who may be regressing or plateaued may be able to regain function and improve both ROM and quality of life.
Continued research and innovation are essential to improving scar and functional outcomes following a burn injury. This single case suggests that further research into multimodal treatment may be beneficial to develop a standardized protocol for therapy intervention.