Burn Rehabilitation

• The burn is a coagulative destruction of the surface layers of the body.
• Damage is usually caused by heat, cold, electrical, and chemical agents.
• Scald burns from hot liquid are the most common in children.
• The presence of inhalation injury reduces the survival rate by 30-50%.

Layers of Skin

• 3 layers: epidermis, dermis, hypodermis

Determined by

• The percent total body surface area (TBSA) burned
• Rule of 9
• Lund & Browder chart for children
• Depth of burn
• Temperature of source
• Time of contact
• Thickness of skin
• Depth of burn at the level of injury

Body Part	Percentage for Adults	Percentage for Children (Infant)
Head	9%	18% (front & back)
Chest	18%	18%
Back	18%	18%
Both Hands	9% each	-
Left Arm	9%	9%
Right Arm	9%	9%
Left Leg	18%	13.5%
Right Leg	18%	13.5%
Perineum	1%	1%

This table outlines the percentage of total body surface area (TBSA) for each body part according to the Rule of 9 for adults and children.

Degrees of Burn

• First-degree burn

  • Involves epidermis.
  • Causes: Mild sunburn, flash burning - a sudden burst of heat.
  • Symptoms:
    • Redness, dry skin.
    • Peeling skin blanches on pressure.
    • Very painful (48-72 hours).
  • Characteristics:
    • The intact protective function of the skin.
    • Healing time: 3-6 days.
    • No residual scarring.

• Second-degree burn

  • Involves the epidermis & part of the dermis.
  • Causes: Deep sunburn, exposure to burn, contact with hot liquids, burning gasoline or kerosene, contact with chemicals.
  • Sub-types:
    • Superficial dermal burns.
    • Complications: Infection.
  • Characteristics:
    • Heals with minimal scarring (10-14 days unless infected).

• Deep Dermal Burn

  • Sensation is reduced (Unable to distinguish sharp & blunt pressure).
  • Scarring is inevitable.
  • Heals more slowly (3-4 weeks).

  Clinical Features

  • Blister: Red, blotchy blister. Blisters continue to increase in size in the post-burn cases.
    • Blister Definition: Serum collection due to leaks from nearby tissue and blood vessels that have been destroyed. Contains water and proteins (albumin, globulin).

  3rd Degree Burn

  • All epithelial elements are destroyed. Involves the epidermis, dermis, and fat.
  • Irreversible destruction of dermal appendages and nerves.
  • No potential for epithelialization.

  Causes

  • Scalding liquids.
  • Flames from fire, electrical sources, and chemicals.
  • Contact with hot object for an extended period.

  Clinical Features

  • White waxy appearance.
  • Swelling, lack of pain.
  • Lack of capillary refill, lack of sensation, and leathery texture.
  • Needs skin grafting.

  Causative Agents of Burn

  1. Electrocution burns.
  2. Building fires.
  3. Thermal burns.
  4. Chemical burns.
  5. Smoke/heat inhalation.
  6. Gas explosion.
  7. Fume ignition.
  8. Gasoline spills.
  9. Flammable clothing.
  10. Motor vehicle fires.
  11. Flammable liquids.
  12. Water heater fires.
  13. Scald/burn from hot liquid.
  14. Defective products.

  Frostbite

  • Occurs at 0°C-4°C degrees.
    • 1st: Erythema, edema.
    • 2nd: Blister.
    • 3rd: Necrosis.
    • 4th: Gangrene.

  Scar Formation

  • Divided into 3 formation phases: Inflammatory, proliferative, and maturation.

  PT Management                                                                                                                                                                         

  Initial Management

  1. Airway
  2. Breathing
  3. Circulation

  Initial Intervention

  • Early intubation
  • Warm humidified O2
  • Care of the cervical spine
  • Taking of the respiratory system
  • Exposed: clothes and jewelry
  • For fluid resuscitation, calculate the fluid requirement

  Phases of Burn Recovery

  1. Emergent phase
  2. Acute phase
  3. Skin grafting phase
  4. Rehabilitation phase

  Emergent Phase

  • First 24-72 hours

  Goals

  • Evaluate the patient & develop a treatment plan
  • Help control edema
  • Initiate and maintain active motion

  Initial Evaluation

  • Observation
    • Wound (e.g., joints involved)
    • Edema
    • Pain (VAS)
    • Available ROM
    • Sensory and motor nerve function
    • Gross and fine motor coordination
    • Activities of daily living (ADLs)

  Edema

  • Develops from 8 to 12 hours
  • Peaks up to 36 hours
  • Begins to resolve after 1-2 days
  • Completely gone by 7-10 days after injury

  Circumferential burn of hand, fingers & extremity

                      ↓
  

  Increase in venous pressure + increase in soft tissue swelling

                      ↓
  

  Increase in pressure > 30 mm Hg (tourniquet effect) Tissue Necrosis

• Deep Dermal Burn

  • Sensation is reduced (Unable to distinguish sharp & blunt pressure).
  • Scarring is inevitable.
  • Heals more slowly (3-4 weeks).

  Clinical Features

  • Blister: Red, blotchy blister. Blisters continue to increase in size in the post-burn cases.
    • Blister Definition: Serum collection due to leaks from nearby tissue and blood vessels that have been destroyed. Contains water and proteins (albumin, globulin).

  3rd Degree Burn

  • All epithelial elements are destroyed. Involves the epidermis, dermis, and fat.
  • Irreversible destruction of dermal appendages and nerves.
  • No potential for epithelialization.

  Causes

  • Scalding liquids.
  • Flames from fire, electrical sources, and chemicals.
  • Contact with hot object for an extended period.

  Clinical Features

  • White waxy appearance.
  • Swelling, lack of pain.
  • Lack of capillary refill, lack of sensation, and leathery texture.
  • Needs skin grafting.

  Causative Agents of Burn

  1. Electrocution burns.
  2. Building fires.
  3. Thermal burns.
  4. Chemical burns.
  5. Smoke/heat inhalation.
  6. Gas explosion.
  7. Fume ignition.
  8. Gasoline spills.
  9. Flammable clothing.
  10. Motor vehicle fires.
  11. Flammable liquids.
  12. Water heater fires.
  13. Scald/burn from hot liquid.
  14. Defective products.

  Frostbite

  • Occurs at 0°C-4°C degrees.
    • 1st: Erythema, edema.
    • 2nd: Blister.
    • 3rd: Necrosis.
    • 4th: Gangrene.

  Scar Formation

  • Divided into 3 formation phases: Inflammatory, proliferative, and maturation.

  PT Management

  Initial Management

  1. Airway
  2. Breathing
  3. Circulation

  Initial Intervention

  • Early intubation
  • Warm humidified O2
  • Care of the cervical spine
  • Taking of the respiratory system
  • Exposed: clothes and jewelry
  • Fluid resuscitation, calculate the fluid requirement

  Phases of Burn Recovery

  1. Emergent phase
  2. Acute phase
  3. Skin grafting phase
  4. Rehabilitation phase

  Emergent Phase

  • First 24-72 hours

  Goals

  • Evaluate the patient & develop a treatment plan
  • Help control edema
  • Initiate and maintain active motion

  Initial Evaluation

  • Observation
    • Wound (e.g., joints involved)
    • Edema
    • Pain (VAS)
    • Available ROM
    • Sensory and motor nerve function
    • Gross and fine motor coordination
    • Activities of daily living (ADLs)

  Edema

  • Develops from 8 to 12 hours
  • Peaks up to 36 hours
  • Begins to resolve after 1-2 days
  • Completely gone by 7-10 days after injury

  Circumferential burn of hand, fingers & extremity

                      ↓
  

  Increase in venous pressure + increase in soft tissue swelling

                      ↓
  

  Increase in pressure > 30 mm Hg (tourniquet effect) Tissue Necrosis                                                                                                          

  • Capillary Blood Flow Assessment:
    • Through evaluation of fingertip capillary refill.
    • Use of Doppler flowmetry to monitor pulses.
  • Positioning & Splinting
  • Wound Dressing:
    • Biological dressing.
    • Biological tissues are used.
    • Provides early wound closure.
    • Reduce Pain, Decrease Infection & Limit Exposure Fluid loss: Cadaveric dura; human fetal membrane

• Synthetic wound dressings:

  • Pre & polyurethanes;
  • Temporary dressings

Acute Phase

• From the emergent phase till wound closure

• Goals: Maintain ROM

  • Maintain tendon gliding through activity;
  • Inhibit contraction of the scar;
  • Promote function;

• Exposed & Ruptured Tendon:

  • Exercise & splinting of exposed tendon:
    • Depends on:
      • Extent & exposure of the tendon;
      • The integrity of tendon & surrounding tissue;
      • Willingness of patient;

• Splinting:

  • To counteract the deforming position of edema,
  • To support the part,
  • To maintain alignment

• Hand & Wrist

  • Palmar surface: burn and graft placement
  • The Horseshoe splint maintains finger position after graft placement.

• Dorsal Surface

  • Intrinsic plus hand splint
  • Wrist 15-20° of extension
  • IP - fully extended
  • Thumb - midway between radial & palmar abduction
  • Thumb MCP 40° flexed & IP fully extended
  • Gutter splint - from only volar surface & only proximal & distal phalanx.

• Elbow

  • The splint should maintain the elbow in flexion or extension depending on the amount used.
  • The splint is removed to perform ROM.

• Axilla

  • Airplane Splint with the shoulder in 70-80 degrees abducted and horizontally adducted 15-20 degrees.

• Scapula:

  • Vertical roll when is supine.
  • The figure of eight strapping.

• Neck:

  • Neck extended conformer splint to position the neck extended, head in midline & provide additional pressure to the scar.
  • Soft collar during the day.
  • 7-10 days.

• Lower Extremity:

  • Positioning of the hip to prevent flexion contracture, the knee should be maintained in an extended position using a posterior splint or knee immobilizer for skeletal traction.
  • The ankle should be maintained in a 90° position using the static splint.