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Scar Management

Information

Description of Intervention

For scars of the hand, whether they are post-operative or post-traumatic in nature, therapy can aid in the patient’s recovery of functionality and aesthetics. Treatment, lasting from 3 to 18 months, can include active exercises, splinting, silicone gels, pressure therapy and laser therapy. Even after extensive rehabilitation, the patient may still experience joint contractures and limited movement. In these cases, surgery may be considered.1

Indications for Intervention

Causes of scars include surgeries, tendon injuries, knife or gunshot wounds, burns and Dupuytren’s contracture.2

Diagnosis

  1. Ask for the patient’s medical history, including any recent hand injuries or second degree burns. Also record comorbidities, including diabetes, rheumatoid arthritis (RA), vascular impairment and immunocompromising diseases.3 Note the time passed since the injury or surgery.
  2. The patient may need pain medication before the examination.3
  3. Check for tissue shortening, tendon tethering and overall stiffness.2
  4. Check active range of motion. If the patient is unable to move the hand actively, gentle passive motion may be used to determine the extent of a burn or injury.1
  5. Encourage the patient to return to active movement as soon as possible, to avoid contractures that may be caused by immobilization, particularly with burns and crush injuries.1

Intervention Options

Scar treatment aims to sustain tissue mobility and joint motion, to remodel collagen tissue, and to repair the aesthetics of the patient’s hands.2 Therapists should use post-surgical or post-traumatic treatment for at least 9 weeks after the surgery or injury. Patients must be instructed that it is important to engage in active motion, in spite of swelling, stitches or open wounds. After Dupuytren’s surgery, this motion may be especially difficult during the time frame 2-3 weeks after the procedure.4   

Patients should be informed and/or reminded that waiting for the swelling to go down or until stitches come out may be too late to initiate active or passive ROM dependent on the protocol.  At this time post injury or surgery, scar tissue will already be building up and edema will have had a chance to pool in the involved extremity (arm, wrist, hand or fingers).

Treatment can include elevation, light massage, active muscle exercise and compression. Massage may benefit collagen synthesis, for scars due to burns, tendon injuries or Dupuytren’s contracture.2 Splinting may be used to correct joint contractures and to help the patient regain functional hand movement. However, among therapists, there is some controversy concerning whether splinting can increase the possibility of contractures. One study showed that night splinting did not aid in healing, after Dupuytren’s disease fasciectomy.2

Hypertrophic scars, which are vascular, red and itchy, can be caused by superficial second degree burns. Before treating these scars, first check the depth, location of the burns and fluid replacement. These scars may need long-term therapy.4 Laser therapy can help to recover texture and color.5 Silicone-based products, with their hydrating properties, are an effective and non-invasive option of pressure therapy treatment. Silicone sheets can aid in making scars softer, flatter and smoother.1,6

Diagnoses Where This Intervention May be Relevant
Comments and Pearls
  • Patients should not smoke, especially during the time of hand therapy; smoking may impede the wound healing process.
  • It may be necessary to lessen the force of exercises, in post-operative therapy, as compared with post-traumatic therapy.
  • Depending on the cause of the scar, the patient may have cognitive or emotional challenges, for example post-traumatic stress. In these situations, counseling should be considered, in conjunction with the patient’s hand therapy.4
References
  1. Salter M, Cheshire L. Hand Therapy: Principles and Practice. Oxford: Reed Educational and Professional Publishing Ltd, 2000.
  2. Jones L. Scar management in hand therapy -- is our practice evidence based? British Journal of Hand Therapy2005;10(2).
  3. Culp R, Jacoby S. Musculoskeletal Examination of the Elbow, Wrist and Hand: Making the        Complex Simple. New Jersey: SLACK Incorporated, 2012.
  4. Wietlisbach C. Cooper’s Fundamentals of Hand Therapy. Missouri: Elsevier, 2020.
  5. Sorkin M, Cholok D, Levi B. Scar management of the burned hand. Hand Clin 2017;33(2):305-15. PMID: 28363297
  6. Meaume S, Le Pillouer-Prost A, Richert B, etal. Management of scars: updated practical guidelines and use of silicones. Eur J Dermatol 2014;24(4):435-43. PMID: 25141160
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