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DEFINITION OF TERMS

II. EPIDEMIOLOGY

Total of 4,563 hospital admissions for burns


between 1993 and 1997
o 25.3 per 100,000 population
The Bradford Burn Study (Khan et al 2007)
o Studied all burns admissions (n=460) for a full
year at a single A&E in the UK
o Children of <10 years accounted for 36% of
admissions
o Wrist and Hand burns accounted for 36% with
upper limb burns constituting a further 21%
(DORAS 2001)
ANATOMY, PHYSIOLOGY, KINESIOLOGY

Skin secretions (acid mantle)


Low pH and sebum slow bacterial
Functions of the Integumentary System growth on skin surface
Protection against injury and Human defensin natural antibiotic
infection Cathelicidins proteins that prevent
Regulates body temperature Strep A infection in wounded skin
Sensory perception Melanin chemical pigment that
Regulates water loss prevents UV damage
Chemical synthesis
Biological Barriers
Protection covers and protects the Langerhans cells, macrophages,
entire body against injury and infection and DNA
Langerhans cells in epidermis
Physical barriers present antigens to lymphocytes
- continuity of the skin and hardness of Dermal macrophages (2nd line of
keratinzed cells defense) attack bacteria and viruses
Due to the skins physical that have penetrated the
characteristics such as the keratinized epidermis
cells and Langerhans cells and macrophages
waterproofing properties of the present in the skin helps activate the
glycolipids. bodys immune system.
Keratin helps waterproof the skin and DNA structure the electrons in
protects from abrasions and bacteria DNA absorb UV radiation and
Glycolipids prevent diffusion of water converts it to heat
and water-soluble substances between Temperature regulation
cells Production of copious amounts of
Continuity prevents bacterial invasion sweat to dissipate heat
Substances that are able to penetrate When body temperature rises and is
the skin: hotter than the external environment
Lipid-soluble substances (i.e., the
oxygen, carbon dioxide, steroids, and blood vessels in the dermal area
fat-soluble vitamins) dilates and sweat glands are
Oleoresins of certain plants (ex. stimulated into activity.
poison ivy and poison oak) Evaporation of the sweat from
Organic solvents (ex. acetone, dry skins surface helps dissipate heat
cleaning fluid, and paint thinner) from the body.
Salts of heavy metals (ex. lead, Constriction of dermal blood vessels
mercury, and nickel) to retain heat
Topical medications as motion When it is cold outside, the dermal
sickness patch blood vessels constrict and pull the
Penetration enhancers blood away
Chemical barriers from the skin and keeps it close to
- (skin secretion and melanin) the body core to protect crucial
Skin secretions such as sebum, internal organs.
human defensins (antimicrobial Cutaneous Sensations
peptides), acid mantle of the skin - cutaneous sensory receptors (see -
retards bacteria growth and/or kills nervous system)
them Meissners corpuscles: light touch
Melanin provides protection from Merkel discs: light touch
UV damage
Pascinian receptors lies in deeper Serous Membranes
dermis/hypodermis & detect deep Line body cavities that have no
pressure contacts opening to the outside
Hair root plexus: sensations from Secrete a watery fluid called serous
movement of hairs fluid that lubricates surfaces.
Hair follicle receptors movement Mucous Membranes
across the surface of the skin Line cavities and tubes that open to
Bare nerve endings: painful stimuli the outside
(chemicals, heat, cold) Synovial Membranes
Excretion/Absorption Form the inner lining of joint
Elimination of nitrogen-containing cavities
wastes (ammonia, urea, uric acid), Secrete a thick fluid called synovial
sodium chloride, and water. It fluid
regulates water loss Cutaneous Membrane also known as
Metabolic Functions skin
Synthesis of Vitamin D increases
calcium absorption in the body Characteristics of Skin
Vitamin D is a fat-soluble vitamin The integument covers the entire
that may be absorbed from the body and is the largest organ ~ 2
intestines or may be produced meters and heaviest organ
by the skin when the skin is exposed 16% of body mass of the body.
to ultraviolet light (particularly Composed of the epidermis and
sunlight).It is converted to dermis
its active form by the body in 2 steps, Pliable, yet durable
occurring first in the liver and Thickness: 1.5 to 6.0 mm
completed in the kidneys. In
its active form, vitamin D acts as a Types of Skin
hormone to regulate calcium Thin - 1-2 mm on most of the body and 0.5
absorption from the intestine mm in eyelids
and to regulate levels of calcium and Hairy
phosphate in the bones. Vitamin D Covers all parts of the body except
deficiency causes palms of hands and soles of feet
Rickets Thin epidermis and lacks stratum
When the body is deficient in lucidum
vitamin D, it is unable to properly Lacks dermal papillae
regulate calcium and phosphate Has more sebaceous glands
levels. If the blood levels of these Fewer sweat glands, sensory
minerals becomes low, the other receptors than thick skin
body hormones may Thick - up to 6 mm thick on palms of hands
stimulate release of calcium and and soles of feet
phosphate from the bones to the Hairless
bloodstream. Covers palms of hands and soles of
Chemical conversion of many feet
substances Thick epidermis and a distinct
Blood Reservoir preferential stratum
shunting of blood as needed lucidum
Epidermal ridges are present due to
Types of Membranes - thin sheet-like well developed, numerous dermal papillae.
structures that protect parts of the body Lacks sebaceous glands, has more
sweat glands
Sense receptors are also more Thick plasma membranes
densely packed.
Layers of the Skin Stratum granulosum
Located above the stratum
spinsosum
Epidermis 3-5 layers of flattened keratinocytes
Types of Cells undergoing apoptosis
Keratinocytes Organelles begin to disintegrate
90 % of epidermal cells are becomes nonliving cells
keratinized Marks the transition between deeper
contains keratin (fibrous protein) metabolically active strata and the
protects and waterproofs the skin dead cells of the superficial strata.
Melanocytes Contains lamellar granules
8% of the epidermal cells Secretes lipid-rich secretion that
produces melanin acts as a water
contributes to skin color and absorbs sealant
UV
light Stratum spinosum
Langerhans cells Located above the stratum basale
Arise from red bone marrow and 8-10 layers of keratinocytes
migrate to the epidermis Some cells retain their ability for cell
Constitute small portion of division
epidermal cells Cells have spinelike projections
Participate in immune responses (bundles of
Easily damaged by UV light filaments of the cytoskeleton) tightly
Merkel cells joins cells
Least numerous of the epidermal to each other.
cells Provides skin both strength and
Found in the deepest layer of the flexibility
epidermis
Along with tactile discs, they Stratum basale
function in Also referred to as stratum
sensation of touch germinatum because this is where
Layers of epidermis new cells are formed
Deepest layer of the epidermis
Stratum corneum Single row of cuboidal or columnar
25-30 layers of dead flat keratinocytes
keratinocytes Growth of epidermis
Shed continuously and replaced by Newly formed cells in the stratum
cells from the basale undergo keratinazation as they
deeper strata are pushed to the surface.
Serves as a water, microbe, injury They accumulate more keratin
barrier during the process
Then they undergo apoptosis
Stratum lucidum Eventually they slough off and are
Present only in thick skin replaced
3-5 layers of clear, flat, dead The process takes about 4 weeks
keratinocytes Rate of cell division in the stratum
Dense packed intermediate basale increases during injury
filaments
Dermis White skin appears pink to red depending
Second deepest part of the skin on amount and oxygen content of blood
Blood vessels, nerves, glands and moving
hair follicles are embedded here in the capillaries of the dermis.
Composed mainly of connective Albinism is an inherited trait where a
tissues (collagen and elastic fibers) person cant produce melanin. The have
Collagen fibers make up 70% of the melanocytes but are
dermis and give structural toughness unable to make tyrsinase (the enzyme
and strength. Elastin fibers are which initiates melanin production) so.
loosely arranged in all directions and melanin is missing in
give elasticity to the skin their hair, eyes, and skin.
Has two layers Papillary Layer and Skin color as diagnostic clues for medical
Epidermal layer. conditions
o Cyanotic (cyan = blue) Ex:
Papillary layer someone who has stopped breathing
Superficial portion of the dermis and the skin appears bluish
Consist of areolar connective tissue o because the hemoglobin is depleted
containing elastic fiber of oxyen
Surface area is increased due to o Jaundice (jaund = yellow) - Buildup
projections called dermal papillae of bilirubin (yellow pigment) in the
which contains capillaries or tactile blood gives a yellowish
receptors appearance of eyes and skin
Epidermal ridges conforms to the indicating liver disease Bilirubin is
dermal papillae produced when red blood cells
get old and are broken down by the
Reticular layer body. Normally it is processed in the
Deeper portion of the dermis liver and then deposited
Consist of dense irregular connective in the intestine so it can come out in
tissue containing collagen/elastic the stool.
fibers o Erythema (ery = red) -
Provides skin with strength and Engorgement of capillaries in the
elasticity dermis indicating skin injury,
Contains hair follicles, nerves, infection, heat exposure,
sebaceous and sudoriferous glands inflammation, allergies, emotional
state, hypertension
Hypodermis o Pallor - paleness, emotional state,
(subcutaneous) Attaches the skin to anemia, low blood pressure
underlying organs and tissues o Bronzing - Addisons disease,
Not part of the skin - lies below the adrenal cortex
dermis
o Bruising (hematoma)- escaped
Contains connective tissue and
blood has clottedhematomas ,
adipose tissues (subcutaneous fat) for
deficiency in Vitamin C or
insulation
hemophilia
Infants and elderly have less of this
o leathery skin - overexposure
than adults and are therefore more
clumping of elastin fibers depressed
sensitive to cold
immune system
o can alter DNA to cause skin cancer
Skin Appearances
o photosensitivity - to antibiotics &
Epidermis appears translucent when there antihistamines
is little melanin or carotene
Skin Color precursor for Vitamin A which is
used to make pigments needed for
genetic factors, environmental factors vision
and volume of blood found in stratum corneum and fatty
areas of dermis and hypodermis layer
Skin Pigments - three pigments are Hemoglobin
responsible for skin color- melanin, Oxygen-carrying pigment in red blood
carotene, hemoglobin cells
Melanin Skin Markings
Located mostly in epidermis
- skin is marked by many lines, creases and
Number of melanocytes are about
ridges
the same in all races
friction ridges: markings on fingertips
Difference in skin color is due to the
characteristic of primates
amount of pigment that melanocytes
allow us to manipulate objects more easily
produce and disperse to
- fingerprints are friction ridge skin
keratinocytes.
impressions
Freckles are caused by the
flexion lines: on flexor surfaces of digits,
accumulation of melanin in patches
palms, wrists, elbows etc skin is tightly
Liver spots are also caused by the
bound to deep fascia
accumulation of melanin
at these points
Melanocytes synthesize melanin
freckles: flat melanized patches vary with
from an amino acid called tyrosine
heredity or exposure to sun
along with an enzyme called
moles: elevated patch of melanized skin,
tyrosinase. All this occurs in the
of the with hair mostly harmless, beauty
melanosome which is an
marks
organelle in the melanocyte.
Two types of melanin: eumelanin
Derivatives of skin - during embryonic
which is brownish black and
development thousands of small groups of
pheomelanin which is reddish yellow
epidermal cells from
Fair-skinned people have more
stratum basale push down into dermis to
pheomelanin and dark skinned people
form hair follicles and glands
have more eumelanin
Skin receptors:
Environmental Factors Your skin and deeper tissues contain
UV light increases enzymatic activity millions of sensory receptors.
in the melanosomes and leads to Most of your touch receptors sit close to
increased melanin production. your skin's surface.
A tan is achieved because the Light touch
amount of melanin has increased as Meissner's corpuscles are
well as the darkness of the melanin. enclosed in
(Eumelanin provides protection from a capsule of connective tissue
UV exposure while pheomelanin They react to light touch and are
tends to break down with too much located in the skin of your palms,
UV exposure) soles, lips, eyelids, external genitals
The melanin provides protection and nipples
from the UV radiation but prolonged These areas of your body are
exposure may cause skin cancer. particularly sensitive
Carotene (carot = carrot) Heavy pressure
yellow-orange pigment Paccinian corpuscules sense
pressure
and vibration changes deep in your Skin Glands
skin. Sudoriferous - sweat glands (sudori =
Every square centimeter of your skin sweat) (ferous = bearing)
contains around 14 pressure 3- 4 million glands in your body
receptors empties onto the skin thru pores or
Pain into hair follicles
skin receptors register pain Two main types of sweat glands
pain receptors are the most Eccrine sweat glands
numerous o Secretes cooling sweat
each square centimeter of your skin o Secretes directly onto the skin
contains around 200 pain receptors o Began to function soon after birth
Temperature o Sweat is composed of 98 percent
Skin receptors register warmth and water and two percent dissolved salts
cold and nitrogenous wastes,
Each square centimeter of your skin such as urea and uric acid
contains 6 receptors for cold and 1 o Helps regulate body
receptor for warmth temperature/aids in waste removal
Cold receptors Appocrine sweat glands
start to perceive cold sensations o Stimulated during emotional
when the surface of the skin drops stress/excitement
below 95 F. They o Secretes into hair folicle
are most stimulated when the surface o Begins to function at puberty
of the skin is at 77 F and are no o Slightly more viscous than eccrine
longer stimulated when the surface of secretions
the skin drops below 41 F. This is o Composed of the same components
why your feet or hands start to go as eccrine sweat
numb when they are submerged in plus
icy water for a long period of time. o lipids and proteins.
o Referred to as cold sweat.
Hot receptors Sebaceous - oil glands (sebace = grease)
start to perceive hot sensations when They are mostly connected to hair
the surface of the skin rises above 86 follicles.
F and are Sebaceous glands are embedded in
most stimulated at 113 F. Beyond the dermis over most of the body.
113 F, pain receptors take over to Absent in the palms and soles.
avoid damage being done to the skin Vary in size, shape and numbers in
and underlying tissues. other areas of the body.
Thermoreceptors Secrete an oily substance called
are found all over the body, but cold sebum. which lubricates the hair and
receptors are found in greater density skin
than heat Mixture of fats, cholesterol, proteins,
receptors most of the time our inorganic salts, pheromones.
environment is colder than our body Coats surface of hair
temperature Prevents excessive evaporation of
The highest concentration of water from skin
thermoreceptors can be found in the
face and ears so your nose and ears Keeps skin soft and pliable
always get colder faster than the rest
of your body on a chilly winter day Inhibits growth of some bacteria.
Sebaceous gland activity increases The tissue here will invariably recover
with puberty, due to the male and unless there is severe sepsis or prolonged
female hormone activity hypoperfusion.
Accumulation of sebum in the ducts
= white pimples if the sebum The depth of the wound develops over time: The
darkens -black heads form burn process peaks at approximately three days.
Acne - inflammation of sebaceous Progression is 3D- zone of coagulation both
gland ducts increases in depth and width (Ever et al 2010).
Ceruminous - modified sweat glands of the
external ear that produce ear wax (cer =
wax)
Open directly onto the surface of the
external auditory canal
(ear canal) or into ducts of sebaceous
glands.
Earwax is the combination of
secretion of ceruminous and
sebaceous glands.
Earwax and the hair combine to
provide a sticky barrier against
foreign items.
Physiology of Burns
An in depth knowledge of pathophysiology of burns,
and their effects both locally and systemically is
necessary to ensure effective management of a
patient with a burn injury.

Zones of Injury and Wound Conversion


The local effect involves three burn zones:
(Hettiaratchy and Dziewulski 2004)

Zone of Coagulation:
the point of maximum damage
Irreversible tissue loss due to coagulation
of constituent proteins.

Zone of Stasis:
Characterised by decreased tissue
perfusion
Potential to rescue the tissue in this zone
Problems such as prolonged hypotension,
infection or oedema can convert this area into
one of complete tissue loss

Zone of Hyperaemia:
IV. ETIOLOGY
Burns can be caused by excessive heat or
cold, by chemicals, ultraviolet light
or radiation.
The most common causes of burns
requiring hospital treatment are:
Scalds from hot fluids or steam are
common in the under fives and the elderly.
-Explosions, flash flame or steam, bonfires,
fireworks, barbeques and the use of
flammable liquids such as petrol. Flash
burns tend to be partial-thickness burns, but
can be deeper if the patients clothes ignite.

Flame burns occur when the patients


clothes, hair or skin catch light. The effect of
damage from house or car fires is
exacerbated by the inhalation of toxic gases
from burning household furniture, leading to
severe inhalation injuries as well as burns. braddom

Contact burns from contact with molten


metal or plastic are common in industry. An
unconscious patient may sustain burns from
contact with a cooker or a hot radiator.
Electrical burns due to electrical current
from plugs, sockets and wiring. Deep
structures can be involved at the current
entry and exit sites on the body. The
patients cardiac status requires close
monitoring.
Elsevier
V. PATHOPHYSIOLOGY/MECHANISM OF INJURY/PATHOLOGY
C

(DOH, Western Australia 2009; Ever et al 2010;


Hettiaratchy and Dziewulski 2004)
May be thermal or non-thermal
1. Flame burns 50%
2. Scalds from hot liquids, e.g. boiling water, cooking
oil 40%
3. Contact burn, e.g. stoves, heaters, irons,
4. Electrical burn, e.g. electrocution
5. Chemical Burns, e.g. Hydrofluoric Acid
6. Friction burn
7. Radiation burn
LINICAL SIGNS AND SYMPTOMS/ PHYSICAL DISABILITIES/ IMPAIRM

Signs and symptoms Loss of facial


Signs and symptoms depend on the type expression
of burn and may include: Teeth malalignment
localized pain and erythema, usually Drooling and
without blisters in the first 24 hours inability to close lips
(first-degree burn) Lower lip eversion
chills, headache, localized edema,
Neck Loss of normal
and nausea and vomiting (more
severe first-degree burn) cervical spine range
thin-walled, fluid-filled blisters of motion
appearing within minutes of the Limited visual fields
injury, with mild to moderate edema Difficulties with
and pain anesthesia, due to
(second-degree superficial partial- decreased neck
thickness burn) range of motion
white, waxy appearance to damaged Trunk Protraction of
area (second-degree deep partial- shoulders
thickness burn)
Kyphosis
white, brown, or black leathery
Functional scoliosis
tissue and visible thrombosed
Decreased
vessels due to destruction of skin
elasticity (dorsum of respiratory function
hand most common site of Breast entrapment
thrombosed veins), without blisters Perineal banding
(third-degree burn) Axilla Type 1: either
silver-colored, raised area, usually at anterior or posterior
the site of electrical contact contracture
(electrical burn) Type 2: anterior and
singed nasal hairs, mucosal burns, posterior contracture
voice changes, coughing, wheezing, with sparing of dome
soot in mouth or nose, and darkened Type 3: anterior and
sputum (with smoke inhalation and posterior contracture
pulmonary damage).
and axillary dome
OkDoKeY
Hands Metacarpophalangea
l extension
deformities
Wrist extension
Potential impairment
deformities
Body area Impairment Proximal
Face Facial disfigurement interphalangeal
(contractures of flexion deformities
eyelids, nose, Interdigital web
mouth, ears, and contractures
adjacent facial skin) Clawing of fourth
Inability to close and fifth digits
eyes Thumb contractures
(adduction,
opposition, flexion,
or extension)
Arms Antecubital banding Electrical burns
and and flexion
legs Posterior popliteal Complications specific to electrical injury
banding and flexion include the following"s:
Anterior hip banding Cardiovascular: Cardiac arrest
(ventricular fibrillation for electric current
and flexion
or asystolic for lightning), arrhythmia
Medial and lateral
(usually sinus tachycardia or nonspecific
malleolar scarring ST changes) secondary to alterations in
Foot Hyperextension of electrical conductivity of the heart,
and metatarsophalangea myocardial contusion or infarction, or heart
ankle l joints wall or papillary muscle rupture
Equinovarus Neurologic: Headache, seizure, brief loss
Cavus foot of consciousness or coma, peripheral nerve
Rocker bottom injury (resulting from ischemia), spinal cord
deformity paralysis (from demyelination), herniated
nucleus pulposus, or decreased attention
and concentration
Systemic Complications of Burn Injury
Orthopedic: Dislocations or fractures
Body System Complications
secondary to sustained
Respiratory Inhalation injury,
muscular contraction or from a fall during
restrictive pulmonary the burn injury
pattern Other: Visceral perforation or necrosis,
(which may OCCur with a cataracts, tympanic
burn on the trunk), membrane rupture, anxiety, depression, or
atelectasis, pneumonia, post-traumatic stress disorder
microthrombi, and adult
Chemical Burns
respiratory distress
syndrome pulmonary complications (e. g. , airway
Cardiovascular Hypovolemiaihypotensio obstruction from bronchospasm, edema, or
n, pulmonary epithelial sloughing) and metabolic
hypertension, complications (e. g., liver necrosis or renal
subendocardial ischemia, dysfunction from prolonged chemical
anemia, and exposure).
disseminated
Ultraviolet and Ionizing Radiation Burns
intravascular
coagulopathy
Gastroinrestina Stress ulceration, Gastrointestinal: Cramps, nausea,
V hemorrhage, ileus, vomiting, diarrhea, and bowel ischemia
genitourinary ischemic co\iris, Hematologic: Pancytopenia (decreased
cholesrasis, liver failure, number of red blood cells, white blood
and urinary rract cells, and platelets), granulocytopenia
infection (decreased number of granular
Renal Edema, hemorrhage,
acute tubular necrosis,
acure
renal failure
paz
leukocytes), thrombocytopenia (decreased o adult respiratory distress
number of platelets), and hemorrhage syndrome (due to left-sided
paz heart failure or myocardial
infarction)
Complications o greater damage than
Possible complications of burns indicated by the surface burn
include: (electrical and chemical
o loss of function (burns to face, burns) or internal tissue
hands, feet, and genitalia) damage along
o total occlusion of circulation in o the conduction pathway
extremity (due to edema from (electrical burns)
circumferential burns) o cardiac arrhythmias (due to
o airway obstruction (neck electrical shock)
burns) or restricted o infected burn wound
respiratory expansion (chest stroke, heart attack, or pulmonary
burns) embolism (due to formation of blood
o pulmonary injury (from smoke clots resulting from slower blood
inhalation or pulmonary flow)
embolism)
burn shock (due to fluid shifts out of added pain, depression, and financial
the vascular compartments, possibly burden (due to psychological component of
leading to kidney damage and renal disfigurement).
failure)
peptic ulcer disease (due to Vascular: Endothelium destruction
decreased blood supply in the OkDoKeY
abdominal area)
disseminated intravascular
coagulation (more severe burn
states)
Deprh Appearance Healing Pain

Su perficial (first-Pink to red 3-5 days by Tenderness to


degree)-epidermis With or without epithelialization tOuch or
injured edema Skin appears intact painful
Dry appearance
without blisters
Blanches
Sensation intact
Skin intact when
rubbed
Moderate partial- Pink ro mortied red 5 days to 3 wks by Very painful
thickness (second or red with edema epithelialization
degree)-superficial Moist appearance Pigmentation
dermis injured with blisters changes
Blanches with slow are likely
capillary refill
Sensation intact
Deep partial- Pink ro pale ivory 3 wks to mas by Very painful
thickness (second Dry appearance granulation tissue
degree)-deep with blisters formation and
dermis injured with May blanch wirh epithelialization
hair follicles and slow capillary refill Scar formation
sweat glands Decreased likely
intact sensation ro
pinprick
Hair readily
removed
Full-thickness- White, red, brown, Not able to No pain, perhaps
entire dermis or black (charred if regenerate an ache
injured fourth degree)
(third degree) or Dry appearance
fat, muscle, and without blanching
bone injured May be blistered
(fourth degree) Insensate to
pinprick
Depressed wound
Source: Data from P Wiebelhaus, SL Hansen, Burns: handle with care. RN
1999;62:52-75.
sulivan
VII. DIFFERENTIAL DIAGNOSIS CONDITIONS
DIFFERENTIAL DIAGNOSIS CONDITIONS
DIAGNOSTIC TOOLS/ PROCEDURES OR TEST
MANAGEMENTS
Depth of Injury Treatment Modalities
Superficial Elevation decreases pain of limb
epidermis Keep wound clean
(First degree) Aloe or other moisturizer reduces dry
skin and itching
If needed (usually in electrical injuries)
therapy to prevent PTSD
Superficial dermis Wound care
(Second degree/ Active exercise
superficial partial Protective garments
thickness) Sunscreen
Therapy to prevent PTSD
Deep reticular Wound care
dermis (Second Anti-inflammatories, analgesics,
degree/deep anti-pruritics
partial thickness) Active exercise
Elevated positioning/orthotics
External vascular support garments
Moisturization and lubrication
Daily living skills
Psychological therapy
Therapy to prevent PTSD
Subcutaneous tissue Same as above.
(Third degree/full Postop positioning/immobilization.
thickness) Possible need for NSAIDs or other
etidronate disodium to prevent
heterotopic ossification (controversial
early treatment).
Therapy to prevent PTSD.
Very slow weaning from analgesics and
anxiolytics.
Vibration for pruritus.
Muscle, tendon, Same as above.
bone (Fourth Deep tendon massage.
degree) Adapted equipment.
(Old term in Prosthetic fitting if indicated.
disfavor and rarely
used)
From Rivers EA, Fisher SV. Burn Rehabilitation. In: OYoung B, Young, MA:
Stiens, SA. PM&R Secrets. Philadelphia: Hanley & Belfus, 1997, with
permission.)
Physical Therapy
Intervention

Positioning and Splinting

A positioning program should begin on the


day of admission. The goals of a positioning
program are to (1) minimize edema; (2)
prevent tissue destruction; (3) maintain soft
tissues in an elongated state; and (4)
preserve function.Positioning strategies for
common deformities are presented in Table
24.4. Examples of proper positioning of
different body segments are provided in
Figures 24.14 through 24.17. Burned areas
should be positioned in an elongated state or
neutral position of function. Splinting can be
viewed as an extension of a positioning
program. There are certain anti-deformity
positions in which patients generally are
splinted; however, positioning is
individualized based on the location of the
burn and which movements are difficult for
the patient to achieve. With the exception of
splints designed to immobilize a skin graft
after surgery, splints should be fabricated for
patients only if ROM or function would be lost
without them. General indications for the use
of splints include (1) prevention of
contractures, (2) maintenance of ROM
achieved during an exercise session or
surgical release, (3) reduction of developing
contractures, (4) protection of a joint or
tendon, and (5) to reduce the overall pain
experience.109, Splint design should be kept
simple so that it is easy to apply, remove,
and clean. Splints are usually worn at night,
when a patient is resting, or continuously for
several days following skin grafting. Splints
should conform to the body part, and care
must be taken to ensure that there are no Active exercise begins on the day of
pressure points that may cause a breakdown admission. Any patient who is alert and able
in healing or normal skin. Splints should be to follow commands is encouraged to
checked routinely for proper fit and revised if perform active exercises of involved body
necessary. Active motion is important, and parts frequently throughout the day. A
splints and positioning are intended to serve patient should perform active exercise of all
as adjuncts to the therapy program until full
active motion can be achieved. Most splints
used for burn injuries are static. This type of
splint has no moveable parts, and maintains
a position or immobilizes an area following
skin grafting (Fig. 24.18). Dynamic splints
also have been used successfully in the care
of patients with a burn injury (Fig.
24.19).112-114 These splints have moveable
parts that allow joint movement. At the same
time, dynamic splints apply a low-load,
prolonged stress that can be adjusted to a
patients tolerance. They offer great potential
for correcting a developing contracture and
the early return of active function in areas of
extensive burn and grafting.The use of
continuous passive motion devices also is
appropriate for certain patients with burn
injuries.If the scar is still active or shows
evidenceof vascularity (red color), pressure
therapy may be successful

Active and Passive Exercise


To keep the healed burned area moist,
it should be lubricated before exercise is
initiated. Care should be taken around areas
of skin grafts, and stress should be applied in
a gentle, prolonged, and gradual fashion. If
the burn wounds are well healed, heating
modalities (e.g., paraffin, ultrasound) may be
used to increase the pliability of the tissue
before exercise therapy. Range of motion in
the area of unhealed burns can be extremely
painful, and patients may voice that they
would rather lose their motion than be
subjected to the additional pain that occurs
with movement. It usually is difficult and
mentally draining on the physical therapist to
push patients to exercise in and through
pain, but it is critical that the therapist be
persistent. Coordinating exercise activities
with the administration of pain medication
can lessen the painful experience for the
patient. Physical therapists should elicit the
assistance of the family and caregivers in
keeping the patient motivated and mobile as
extremities and trunk, including unburned much as possible.
areas. Dressing changes are an opportune
time for exercise because the burn wound is
visible and the therapist can monitor the
wound during movement. In the presence of
a recent skin graft, active and passive
exercise of the area may be discontinued for
a period of time to allow the graft to adhere.
After the surgeon determines it is safe to
begin exercise again, gentle ROMfirst
active and then passive, if neededis
reinstituted. Active-assistive and passive
exercise should be initiated if a patient
cannot fully achieve active ROM.
responses to
treatment.
Overexertion
may occur.
Monitoring of
pulse, blood
pressure, and
respiratory rate
before, during,
and after
exercise,
particularly in
the recovery
period after
exercise, will
yield valuable
information as
to the status of
the
cardiovascular
and pulmonary
systems (see
Chapter 2,
Examination of
Vital Signs).
Patients should
Resistive and Conditioning Exercise be encouraged to participate in exercises
that will stress the cardiovascular system,
If the scar is still active or shows evidence of such as walking from the burn unit to the
vascularity (red color), pressure therapy may physical therapy department. Cycling or
be successful rowing ergometry, treadmill walking, stair
climbing, and other forms of aerobic exercise
As a patient continues to recover, the should be encouraged. These activities will
rehabilitation program can be progressed to not only increase cardiovascular endurance,
include strengthening exercises. Patients but can have the added benefit of improving
with major burns may lose body weight, and strength and ROM of the extremities. In
lean muscle mass can decrease addition, they introduce variety into the
rapidly.Exercise may consist of isokinetic, rehabilitation program. The physical
isotonic, or other resistive training devices. therapist needs to be creative and innovative
General principles of exercise training and to motivate patients to increase their
strength improvement should be followed, exercise capacity.
but they may need to be modified on the
Ambulation
basis of a patients condition and stage of
wound healing. Resistive devices such as If the scar is still active or shows evidence of
free weights and pulleys can be used to
vascularity (red color), pressure therapy may
prevent loss of strength in areas not burned.
When a patient initially begins strengthening be successful
or conditioning (endurance) exercises, the
physical therapist should monitor vital signs Ambulation activities should be initiated at
to assess cardiovascular and respiratory the earliest appropriate time. If the lower
extremities (LEs) are skin grafted, localized edema. The early hypertrophic scar
ambulation may be discontinued until it is is readily influenced by compressive forces
safe to resume. When ambulation is initiated and thus will respond to pressure therapy.
after a skin graft, the LEs should be wrapped The earlier the scar tissue is exposed to
in elastic bandages in a figure-of-eight pressure, the better the result. Usually, if the
pattern to support the new grafts and scar is less than 6 months old, it will respond
promote venous return. If a patient cannot to pressure therapy by conforming to the
tolerate the upright position because of pressure, remaining flat on the surface, and
orthostatic intolerance or pain from the LEs not developing into a hypertrophic scar. If
being in a dependent position, gradual the scar is still active or shows evidence of
increases in tilt-table treatment time will vascularity (red color), pressure therapy may
assist in preparing the patient for standing. be successful, even if the scar is as much as
Initially, a patient may require an assistive 1 year old. In general, if wounds heal in less
device to ambulate. However, independent than 10 to 14 days, which would be
ambulation without an assistive device indicative of a superficial partialthickness
should be achieved as soon as possible. The burn, pressure may not be needed. If wound
physical therapist will spend a great deal of healing takes longer than 10 to 14 days (as
time with an individual patient during each in a deep partial-thickness burn) or is skin
treatment session. The rewards of a grafted, pressure usually is indicated
successful POC are tremendous when a
patient who has suffered a life-threatening Pressure Dressings
burn is able to walk out of the hospital and
return to productive community involvement. If the scar is still active or shows evidence of
vascularity (red color), pressure therapy may
Scar Management be successful
If the scar is still active or shows evidence of Elastic wraps can be used to provide
vascularity (red color), pressure therapy may vascular support of skin grafts and donor
be successful sites, as well as to control edema and
scarring. Elastic wraps should be used until a
Following wound closure, a skin graft or patients skin or scars can tolerate the
healed burn wound is vascular, flat, and soft. shearing force of pressure garment
During the following 3 to 6 months, dramatic application, and open areas are minimal.
changes may occur. The newly healed areas Elastic wraps are applied in a figure-of-eight
may become raised and firm. Pressure has pattern on the LEs. A spiral wrap can be used
been used successfully to hasten scar on the upper extremities (UEs) and a circular
maturation and minimize hypertrophic scar wrap on the trunk. A self-adherent elastic
formation. However, no one study validates bandage can be used for the hand and toes.
the mechanism by which pressure alters scar This bandage adheres only to itself and can
tissue. Pressure may exert control over be used over dressings before the wounds
hypertrophic scarring by (1) thinning the have healed. It helps to minimize edema and
dermis, (2) altering the biochemical structure control scar formation. It may be used before
of scar tissue, (3) decreasing blood flow to application of a customized pressure glove or
the area, (4) reorganizing collagen bundles, as definitive pressure on an infants hand.
or (5) decreasing tissue water content. Tubular support bandages come in various
Constant pressure dressings or garments circumferences and garment styles. They
exerting pressure exceeding 25 mm Hg will provide a moderate amount of compression
decrease the vascularity, decrease the and may be used as interim garments before
amount of mucopolysaccharides, decrease a custom-made garment is fitted. The tubular
collagen deposition, and significantly lessen support bandage is especially useful for
small children who grow rapidly and require silicone polymer gel may be applied directly
frequent alterations in garment size. Several over an actively maturing scar. There are
companies manufacture pressure garments. varying sizes of these silicone gel sheets.
Some are ready made and come in several The mechanism of action for the treatment
sizes to fit most patients; others are custom outcome is unknown. The only reported
made for the individual patient. For custom- complication with silicone gel sheet use is a
made garments, the physical therapist uses local rash with the potential, though rare, for
a tape measure to determine the periodic skin breakdown. Rashes that develop are
circumference and linear length of each limb readily reversible by temporarily deferring
and trunk or face so fit of the garment is the use of the gel sheet. Once the site is
exact to apply proper pressure. Garments are clear of the rash, the gel sheet can be
measured when a patient has only a few reapplied.
remaining open areas. The garments are
very tight, and difficult to apply, but the Massage
pressure is necessary to prevent scar
Massage is an intervention that clinically
hypertrophy. Garments can be ordered for
appears useful to assist with ROM exercise
any or all body parts, including the face and
by making the tissue more pliable. Deep
head, and they come in many styles, options,
friction massage is thought to loosen scar
and colors As mentioned, garments can be
tissue by mobilizing cutaneous tissue from
worn when the skin or scars can tolerate the
underlying tissue and acting to break up
shearing force of application. Pantyhose may
adhesions. When massage is used in
be used under waist-height pressure
conjunction with ROM exercise, the immature
garments to assist with donning. Garments
scar can be elongated more easily, and a
usually are worn 23 hours a day (removed for
developing contracture can be corrected.
bathing) for as long as 12 to 18 months to
Although no study has validated the use of
assist with scar remodeling. Garments should
massage for patients with burn injuries, in
be washed daily to prevent buildup of
the long term, skin pliability and texture
perspiration and moisturizing cream, which
appear to be improved by the use of
may lead to scar maceration. The patient
massage. Firm scars that are routinely
usually receives two sets of garments, one to
massaged tend to soften. Edges or seams of
wear and one to wash. Adequate pressure
grafts or any area that is raised and firm may
may not be obtained with elastic wraps or
benefit from massage.
pressure garments over concave surfaces,
such as the sternum or axilla. In these Camouflage Make-up
instances, an insert may be necessary.
Inserts can be made of many materials, For scars of the face, neck, and hands,
including foam, silicone elastomer, elastomer
camouflage makeup can be used.This type of
putty, and gel pads.These items also need tomake-up may be useful when a person has
be removed and cleaned regularly to prevent either hyperpigmentation or
maceration of the underlying tissue. Early, hypopigmentation of the skin due to the burn
consistent use of pressure will result in flat,
injury. In addition, make-up can be used
pliable scars, desensitization and protection
before scar maturation, when the scar is still
of scars, and relief of itching. Pressure isred, and a patient wants to go out in public
necessary until scar maturation, when the without his or her pressure garments or
scars are pale, flat, and soft. devices for short periods of time. The
cosmetics are opaque, colorcorrect burn
Silicone Gel scars, and are available in multiple shades to
accommodate various skin colors. They also
Silicone gel has demonstrated effectiveness
are waterproof and can be worn during all
in managing hypertrophic scar. Sheets of
activities. These products can be purchased
in larger department stores or where wound. The patient should be instructed to
theatrical products are sold. wash these areas twice daily, apply a small
amount of antibiotic ointment, and cover the
Follow-up Care areas with a nonadherent dressing. Avoiding
shearing forces, improper fit of clothing,
Well before patients are discharged from the
brisk cleansing, and soaking in water too
hospital, the therapist should provide
long, or application of too much cream, can
information regarding a home exercise
help prevent further irritation or maceration.
program (HEP), a splinting and positioning
Itching may intensify when wounds have
program, and skin care. An HEP should
healed. A patient should be instructed to pat,
continue to stress frequent ROM exercises in
rather than scratch, the irritated areas.
combination with massaging areas involved
Application of cream may help decrease
in the burn injury. In addition, patients should
itching; however, some patients may require
be encouraged to perform as many ADL
oral antihistamine medication to help control
skills as possible independently. Therapists
this problem. Some patients with burn injury
can videotape the patients exercise program
may require outpatient therapy to
to provide the patient, family, and outpatient
supplement the HEP and monitor and adjust
therapist with the actual ROM and movement
their splinting and pressure program.
pattern used in each exercise. Instructional
Frequency of outpatient therapy is based on
programs (videotape, compact disc) facilitate
each patients needs. Regardless of whether
education of those involved in the patients
or not a patient receives outpatient therapy,
rehabilitation program and will help to
he or she should be monitored at regular
ensure consistency of treatment after
intervals through an outpatient clinic. This
discharge. The splinting schedule and
will allow burn team members to evaluate
pressure program that was followed in the
adjustment back into society and alter the
hospital just before the patients discharge
rehabilitation program according to the
should be continued at home. Before
patients physical abilities and extent of scar
discharge, the patient and/or his or her
maturation. When an adult patients burns
family members and caregivers should be
have matured and full ROM is achieved,
able to apply and remove all splints and
further follow-up care is unnecessary.
pressure appliances independently. Proper
However, a child will need to be monitored
skin care requires specifying the type of soap
until he or she is fully grown, because burn
and cream a patient is to use. In general,
scars may not keep pace with a childs
soap should be mild without perfumes or
growth. In these cases, surgical release of
other irritants. A moisturizing soap can be
scar tissue may be necessary
used after all open areas are healed.
Moisturizing creams should be applied 2 to 3
times daily and should not contain perfumes
or have a significant alcohol content. Patients
should be instructed to massage the cream
completely into their skin to avoid buildup on
the surface. If a patient will be unavoidably
exposed to the sun, a sunscreen with a skin
protection factor of at least 30 should be
used and reapplied frequently. Patients
should be cautioned to avoid the sun if at all
possible and to use hats or clothing to help
protect their skin against the suns rays.
Small, superficial open areas may plague a
patient for many months after wound closure
because of the fragility of a healed burn
REFERENCES