Vita TU, Project Manager and Occupational Therapist,
Sunshine Social Welfare Foundation
You’ve probably seen this kind of hand before. It’s been a while since the patient’s injury, but his hands still look swollen. The patient also complains that the swelling causes stiffness when making finger movements. You immediately identify edema. Should you be worried? Is it serious? Will it eventually dissipate by itself?
The fact is, whether it occurs in the acute phase or much later during the rehabilitation phase, edema should not be taken lightly because if it is left untreated, edema can cause serious and long-lasting damage to hand functions. In this post, we’ll explain why edema is serious and why therapists should never overlook or underestimate its impact when dealing with burned hand.
What is edema?
Edema is a normal response to burn injury. The inflammatory response post-burn will cause limbs to swell. Edema will affect both injured and non-injured areas. According to literature, up to 50% of the tissue fluid after edema will be distributed in the non-burned area [1].
After the injury, the permeability of the microvessels throughout the body will increase, causing fluids and proteins to seep out into the tissues, resulting in systemic edema. Accumulation of fluids in tissues will increase negative pressure in the interstitial space, compressing blood vessels and reducing blood circulation. The compression of blood vessels can even result in tissue necrosis.
At the same time, proteins accumulate in tissues, causing fibrosis or thickening of tissues. When fibrin starts to accumulate in the various structures of the hands, such as the tendons, tendon sheaths, joint capsules, synovial membranes and fascia layers, it will cause adhesion between structures, which becomes dense fibrous tissue, and then scars. Persistent swelling will lead to thickening and shortening of the aforementioned structures, which will cause functional limitation. So even a small volume of edema fluids can interfere with the recovery of the hand [1].
What is the long-term impact of edema on the hand?
When left untreated or with improper management, edema can result in serious hand deformities. The most common deformities are claw hand deformity and intrinsic tightness.
Claw hand deformity
Because the skin on the back of the hand is relatively loose, edema fluid will easily accumulate there. Swelling will increase tension on the skin, which will pull the metacarpophalangeal joints into hyperextension and the wrist in flexion [2]. If the metacarpophalangeal joints are in hyperextension for a prolonged period of time, the muscle fibers of the extensor muscles and the collateral ligaments of the metacarpophalangeal joints will become shortened, while the joint capsule on the dorsal side will become tight. When tissue adhesion caused by the accumulation of edema protein on the back of the hand is added to the mix, claw hand deformity will continue to develop and become more pronounced.
Intrinsic tightness
Edema and accumulation of proteins in the palms of the hand can also cause adhesion and fibrosis of the palmar muscles [3]. When pain is present, it impedes joint movement, increasing the likelihood of adhesion and joint contracture.The palmar muscle fibers are small and prone to ischemia due to pressure. Therefore, when the upper limb has compartment syndrome, special attention should be paid to the possibility of intrinsic tightness due to ischemia and fibrosis of the intrinsic muscle [2]. When a patient has intrinsic tightness or fibrosis of the intrinsic muscles, the hand will tend to remain in the position of MP flexion and IP extension while it is in resting attitude; and when the patient is asked to perform MP extension, the metacarpophalangeal joints will not be able to extend in full, while the proximal interphalangeal joints will be hyperextended.
Whether it’s dealing with systemic edema in the acute phase or recurrent and localized edema in the later rehabilitation phase, therapists must actively control and reduce edema. By preventing excessive accumulation of tissue fluid and protein, the therapist can avoid fibrosis of soft tissues, adhesion of tendons, and thus prevent joints from being immobilized for a long time, resulting in insufficient range of motion or even deformity. Edema control is a crucial step towards helping our patients regain better hand functions.
To learn more about the management of edema, please check out the course “Assessment and Management of Hand Edema” in the course series Rehabilitation of the Burned Hand – Basic Concepts.
To learn more about how to prevent and manage claw hand deformity and intrinsic tightness, please check out our course series Rehabilitation of the Burned Hand - Management of Common Post-Burn Hand Deformities.
References:
1. Dale Wesley Edgar, Joel S. Fish, Manuel Gomez, Fiona Melanie Wood. Local and Systemic Treatments for Acute Edema After Burn Injury: A Systematic Review of the Literature. J Burn Care Res 2011;32:334–347.
2. Sameek Bhattacharya. Avoiding unfavorable results in postburn contracture hand. Indian Journal of Plastic Surgery 2013; Vol 46 Issue 2: 434-445.
3. Nader Paksima, Basil R. Besh. Intrinsic Contractures of the Hand. Hand Clin 2012; 28: 81–86.