1 - Burns

How are burns classified?

• Depth of damage to the skin

• The area of skin damaged

• Length of time

• Type of exposure

• Area of the body affected

Superficial

• Affect only the epidermis

• Does not cause scarring

• Ex: Sunburn

Superficial Partial-Thickness

• Destroy the epidermis and damage part of the papillary dermal layers

• Blister forms over the burn

• Pain is present due to irritation of the nerve endings

• Usually heals within 10 days

• Minimal scarring

Deep Partial-Thickness

• Destroys the epidermis and damages the dermis as far down as the reticular layer

• Significant damage to nerve ending, blood vessels, hair follicles and sweat glands

• Often have severe edema

• Usually heal in 3-5 weeks

• Keloid and hypertrophic scarring are common side effects

Keloid scarring

An excessive amount of healed tissue that extends beyond the parameters of the original wound

Hypertrophic scarring

Raised scar, but isolated to the area of the original wound

Full-thickness

• Destroy dermis, epidermis and possibly underlying fat tissue

• Main characteristic is eschar

• No sensation because of destruction nerve endings

• Hair follicles and dermal glands are destroyed

• Eschar is breeding ground for bacteria → infection

• Do not heal without surgical intervention

Subdermal Burns

• Destroy epidermis, dermis, and all other tissues (fat, bone, muscle)

• Usually caused by flame or electrical shock

• Surgical intervention required for healing, Amputation may be needed

• Often fatal, esp. if involves trunk

Electrical burns

• Damage to other areas of the body may not be known until later

• Blood vessel damage may result in gangrene

• Spinal cord may be damaged

Rules of 9s

• 9% head

• 9% each UE

• 18% each LE

• 18% Ant trunk

• 18% Post trunk

Potential complications of burns

• Infection

• Cardiac arrest (usually with electrical burns)

• Smoke inhalation

• Inhalation of noxious chemicals

• Pneumonia

• Hypothermia

• Scarring that reduces functional activity

PT interventions for burns

• Wound care

• Positioning

• Stretching of scar tissue

• Maintaining of joint range of motion

• Whirlpool (maybe)

• Prevention of muscle atrophy

• Pressure garments

Inflammatory phase

• • Ends about 3-5 days after injury

• Characterized by redness, edema, warmth, pain and decreased ROM

Proliferative phase

• Re-epithelialization occurs at the surface of the wound

• Fibroblasts are synthesizing scar tissue

• Collagen is being deposited

• Granulation tissue is formed

• Wound contraction occurs

*Prevention of contracture is key!!!

Maturation phase

• Remodeling of the scar tissue

• If the rate of collagen production exceeds collagen breakdown, a hypertrophic scar may result

*Very important for preventing development of contracture!!

Benefits associated with compression include its ability to:

• Protect fragile skin

• Promote better circulation of damaged tissues

• Decrease extremity pain through vascular support

• Decrease itching

• Reduce thick, hard scars

• Increase skin length by putting pressure on contracture bands

• Typically begin using compression garments 2 weeks- 2 months after wound closure or grafting

What pressure should be used with compression?

*There is lack of conclusive information regarding appropriate pressure

• 25 mmHG most commonly recommended amount of pressure

• Some research shows that as little as 10 mmHg is effective

• 25-35 mmHg may induce more rapid maturation of hypertrophic scars

• Pressure > 40 mmHg may cause maceration or paresthesias

Compression garments should be worn 7 days a week, 23 hours per day.

True

It takes between 8 months up to 1-2 years before scars are mature (depending on depth, genetics, etc.).

True

Concerns with compression garmets

• Hot

• Restrict movements

• Appearance

• Cost of custom-fit garments

• Elasticity may vary

• Does not apply equal pressure to all areas (face)

• May cause retardation of soft tissue growth

• About 44% compliance in adults

Given current evidence, additional research is required to examine the effectiveness, risks and costs of PGT.

True

Splinting

• Purposes:

  • Prevention of contraction

  • Maintenance of ROM Reduction of developing contractures

  • Protection of a joint or tendon Reduce overall pain experience

• Usually worn at night

• Need to be checked reguarly

• Most are static (can be dynamic)

Important considerations for burn management

• Coordinate exercise with administration of pain medication

• To keep the healed burned area moist, it should be lubricated before exercise is initiated

• When initiating strengthening or conditioning exercises, vital signs should be monitored