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CASE REPORT
Year : 2017  |  Volume : 25  |  Issue : 1  |  Page : 85-87

The role of regional block analgesia in the early functional recovery of burns in the hand


Department of Plastic Surgery, Army Hospital Research and Referral, New Delhi, India

Date of Web Publication13-Dec-2017

Correspondence Address:
Sandeep Mehrotra
Department of Plastic Surgery, Army Hospital Research and Referral, New Delhi 110010
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijb.ijb_25_17

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  Abstract 

Patients with upper limb and hand burn suffer from a higher pain perception due to higher density of nerve endings and larger cortical representation compared to other regions. This unfortunately leads to reduction of movement, increasing edema and stiffness. This initiates a vicious cycle leading to prolonged morbidity and repeated interventions. In our burn centre we are routinely practicing regional supraclavicular analgesic blocks for hand burn. We have found this technique immensely beneficial in pain relief, promoting early healing with restoration of range of motion (ROM) and functional recovery.

Keywords: Extremity burn, functional rehabi litation, regional block analgesia


How to cite this article:
Mehrotra S, Dua A, Singh V, Mehare S, Kaundal R. The role of regional block analgesia in the early functional recovery of burns in the hand. Indian J Burns 2017;25:85-7

How to cite this URL:
Mehrotra S, Dua A, Singh V, Mehare S, Kaundal R. The role of regional block analgesia in the early functional recovery of burns in the hand. Indian J Burns [serial online] 2017 [cited 2018 Nov 18];25:85-7. Available from: http://www.ijburns.com/text.asp?2017/25/1/85/220655

The functional component of burn in the hand makes their management critical. Prolonged healing time, pain, and stiffness commonly interfere with functional rehabilitation and lead to suboptimal outcomes. Therapeutic exercises encompass the mobilization of joints with improved motor power, balance, and endurance but necessitate pain-free physiotherapy.[1]

Patients with burns in the upper limb and hand suffer from a higher pain perception due to a higher density of nerve endings and larger cortical representation compared to other regions. This unfortunately leads to a reduction of movement, increasing edema and stiffness. This initiates a vicious cycle leading to prolonged morbidity and repeated interventions.

Initially, patients with burn involving the upper limb are instructed on proper positioning to control edema and maximize early active range of motion (AROM) and function. The increased edema in burn of the extremities results in limitations in range of motion (ROM) (especially in the hands). Patient compliance with their exercise program is the most critical factor in their achievement of full functional AROM and the use of the involved extremities.[2]

Regional anesthesia is routinely used for corrective surgery of burns of the hand but sparingly for recovery. For analgesic purposes, regional block techniques can be used in relieving pain caused by burns involving the upper limbs and for improving compliance to physiotherapy.[3]

In this case study, a 32-year-old right hand dominant soldier sustained second-degree burn following electrical flash. The burn involved both the hands. The patient arrived at our burn center on the second post-burn day with complaints of pain. The patient had hand edema and stiffness. Burns were assessed as mixed second degree.

It was decided to employ bilateral supraclavicular analgesic blocks administered through pumps for pain relief and hand mobilization. This is a routine practice in our institute to give blocks in cases such as frostbite and post-trauma. Contiplex® Stim Set, 18 Ga. × 2 in. Insulated Tuohy Needle and Stimulating Catheter (SCNB2; B Braun, USA) was used. The stimulating needle with Tuohy tip was used under ultrasound guidance to locate the supraclavicular brachial plexus and insert the contiplex stim catheter (closed tip catheter with three lateral holes) 2 cm beyond the needle tip. After the catheter was fixed, a continuous infusion of 0.125% bupivacaine was run using Baxter elastomeric infusion pump (multirate infusor) at the rate of 5 ml/h and planned to be continued for the next 7 days.[4]

The right supraclavicular pump malfunctioned and was removed while the left one continued to work. This allowed us an opportunity to compare outcomes with and without this technique. The daily monitoring of healing and the functional recovery of the smaller joints of both the case and control hands were noted.

The matron in charge of the patient with burns along with a physiotherapist ensured physiotherapy twice a day comprising five sets of ten movements each with complete fist formation. In the right hand without regional block, the patient resisted hand movements and could not achieve full fist formation for 2 weeks. The patient had 80% pain relief when compared to the opposite limb as per the pain scale. At 0.125% concentration of bupivacaine, it acted as a sensory block preserving motor function, allowing active exercises. This helped him in regaining early functional recovery and full ROM of the left hand within 7 days of therapy. In the right hand finger, the palm distance was 3.5 cm for the index and 3 cm, 2 cm, and 1.5 cm for the middle, ring, and little finger, respectively, after 1 week. On the other hand, complete fist formation was achieved in the left hand from day 2. Pain and stiffness had precluded full ROM recovery in his right hand even 2 weeks after the burns [Figure 1].
Figure 1: Photographs showing the patient with good functional recovery of mixed burns in his left hand after a 1-week period of physiotherapy. Quick recovery was because of the left upper limb regional block effect

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In our burns center, we routinely practice regional supraclavicular analgesic blocks for burns in the hand. We have found this technique immensely beneficial for pain relief, promoting early healing with the restoration of ROM and functional recovery. Catheters allow the continuous or intermittent administration of anesthetic solutions, promoting passive and active physical therapy, preventing post-burn joint limitations, and scar contraction.[4]

We have not seen any complication apart from catheter blockage. Sterile dressing is applied, and the pump can be easily carried in the pockets of small handy bags. We follow and recommend this technique for its multiple benefits.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Richard R, Baryza MJ, Carr JA, Dewey WS, Dougherty ME, Forbes-Duchart L et al. Burn rehabilitation and research: Proceedings of a consensus summit. J Burn Care Res 2009;30:543-73.  Back to cited text no. 1
    
2.
Perera MM, Nanayakkarawasam PP, Katulanda PP. Effects of burns on the mobility of upper limb/s, functions of hand/s & activities of daily living. Int J Physiother Res 2015;3:832-8.  Back to cited text no. 2
    
3.
Morgan GE, Mikhail MS, Murray MJ. Peripheral nerve blocks. Clinical Anesthesiology. 4th ed. New York: McGraw-Hill Medical; 2006. p. 283-308. ISBN 978-0071423588.  Back to cited text no. 3
    
4.
Gelpi B, Telang PR, Samuelson CG, Hamilton CS, Billiodeaux S. Bilateral ultrasound-guided supraclavicular block in a patient with severe electrocution injury of upper limb extremities. J La State Med Soc 2014;166:60-2.  Back to cited text no. 4
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