BURN (1).pptx

BURNS
BPT 8th Batch
Submitted to :
Lect. Regan Shakya
Department of
physiotherapy

CONTENTS
• Introduction
• Epidemiology
• Classification
• Clinical feature
• Immediate treatment
• Medical treatment

Contents
• Acute and sub-acute physiotherapy management
• Rational of aerobic and Resistance training
• Aerboic trainning
• Resistanace trainning
• orthoses in burn management
• Types of orthosis for upper and lower extremity

Contents
● Complications of burn
● Scar tissue general information
● Scar tissue management
● Skin graft general information
● Skin graft management
● Evidences

INTRODUCTION
• A burn is an injury to the skin or other organic tissue
primarily caused by heat or due to radiation, radioactivity,
electricity, friction or contact with chemicals.

EPIDEMIOLOGY
• An estimated 180 000 deaths every year are caused by burns-
the vast majority occur in low- and middle-income countries.
• Burns are among the leading causes of disability-adjusted life-
years (DALYs) lost in low- and middle-income countries.
• Females have slightly higher rates of death from burns compared
to males.
• Adult women, children are particularly vulnerable to burns.
WHO 6th march, 2018

EPIDEMIOLOGY IN NEPAL
• Nepal government estimates that there were 55,000 burn cases
and 2100 deaths in 2008.
• 5% of disabilities at all age group in Nepal are due to burns related
injury.
• Flame burns were found to be most common cause of burn injury
followed by scald burns.
• Scald burns were most common among pediatric population.
• Flame burn common among the female patients whereas electric
burns common among the male patient
Sanjib Tripathee et.al; Epidemiology of burn injuries in Nepal, a systematic review

ANATOMY OF SKIN
Skin is a cutaneous membrane that covers our body and
protects us from microbes, and the elements, helps regulate
body temperature, and permits the sensation of touch, heat
and cold.
• It has 3 different layers:
1. Epidermis
2. Dermis
3. Hypodermis

CONTD….
When the skin is burn it damages the cells and proteins
within them.
The number of skin layers affected determines the burn
degree.

PATHOGENESIS
Zone of coagulation
• This occurs at the point of maximum damage.
• In this zone there is irreversible tissue loss due to
coagulation of the constituent proteins.
Zone of stasis
• The surrounding zone of stasis is characterised by
decreased tissue perfusion.
• platelets aggregate, vessels constrict
• The tissue in this zone is potentially salvageable.

CONTD…
• Additional insults—such as prolonged hypotension, infection,
or oedema—can convert this zone into an area of complete
tissue loss.
Zone of hyperaemia
• In this outermost zone tissue perfusion is increased.
• The tissue here will invariably recover.

CLASSIFICATION
Etiological
classification
• Thermal burn
• Electrical burn
• Chemical burn
• Radiation burn
• Friction burn
On the basis of
depth
• First degree
• Second degree
• Third degree
• Fourth degree
Burns: Definition, Classification, Pathophysiology and Initial
Approach Garcia-Espinoza JA et al ,general medicine 2017

THERMAL BURN
• Occurs when come in contact with something
hot
• Thermal burns are associated with
1. Flames or fire
2. Hot, molten liquid or steam
3. Hot objects such as cooking pan, iron or
heated appliances

TYPES OF THERMAL BURNS
✔Flame burns due to contact
with flames
✔Scalding injury due to contact
with hot liquids
✔Contact injury due to contact
with hot or cold solids
✔Flash burns due to gas
explosions

CHEMICAL BURN
• Occurs when skin and eye comes in contact with a
harsh irritant such as acid.
• Substances that cause chemical burn includes:
1. Chlorine
2. Ammonia
3. Bleach
4. Battery acid
5. Strong or harsh cleaners
6. Hydrochloric acid

ELECTRICAL BURN
• Occurs when body comes in contact with electrical
current(Touching and grasping electrically live objects,
Short circuiting, Inserting fingers into electrical sockets,
Falling into electrified water, Lightning strikes)
• Differ from thermal and chemical burns as they cause
much more subdermal damage
• Factors that determine severity of the damage caused by
electrical burns are:voltage ,Current, Resistance
,frequency

RADIATION BURN
• Damage to the skin or other biological tissue as an effect of
radiation.
• Types of radiation
a) Thermal radiation
b) Radio frequency energy
c) Ultraviolet light
d) Ionizing radiation
• Cancer patient undergoing radiation therapy may suffer
from radiation burn

Acute radiation burn - during
radiotherapy for breast cancer
Burn due to radiation

FRICTION BURN
Occurs by the friction of skin rubbing against a surface.
• Dermal papillae may get exposed after top layer of
dermis have been removed
• Friction with abrasive surface such as cloth, carpet,
rope lead to friction burn.

Burn blisters due to
friction with socks
Turf burn in players

CLASSIFICATION OF BURN ON THE BASIS OF
DEPTH

SUPERFICIAL (FIRST-
DEGREE) BURNS ON THE
ARM
SUPERFICIAL PARTIAL-
THICKNESS (SUPERFICIAL
SECOND-DEGREE) BURNS
Outpatient Burns: Prevention and Care
EMILLIA C. O. LLOYD, et al AAFP 2012

BLISTERS SEEN
INSUPERFICIAL PARTIAL-
THICKNESS
(SUPERFICIAL SECOND-
DEGREE) BURNS
DEEP PARTIAL-
THICKNESS (DEEP
SECOND-DEGREE)
BURNS
Outpatient Burns: Prevention
and Care EMILLIA C. O.
LLOYD, et al AAFP 2012

Fourth degree burn :Fourth-degree burns destroy
all skin layers and extend into muscle, tendon, or
bone

CLINICAL FEATURES
• At the site of burn( local effect)
–Redness and erythema
–Altered sensation
–Blister formation
–Blackened skin which is leathery in nature
–Weeping plasma which is straw colored in nature
–pain
–edema

CLINICAL FEATURES
• systemic effect
–Hypovolaemic shock
–Hypothermia
–Metabolic change
–Compartment syndrome
–immune respones is reduced due to receptor down
regulation → increased risk of infection
–bronchoconstriction and acute respiratory distress
syndrome due to inhalation of smoke

CLINICAL FEATURES
• During shock
– Restlessness
– Coldness and paleness of skin, cynosis
– Thirst because of loss of fluid and dehydration,
Sweating
– Decreased blood pressure
– cardiac output is decreased because of reduced
myocardial contractility, increased afterload and
reduced plasma volume
– Tachycardia
– Core body temperature ↓ at large burn

CLINICAL FEATURES
• Compartment syndrome is characterized by muscle and
tissue damage and reduced blood flow, caused by the
compression of nerves and blood vessels in an enclosed
space (eg, as a result of swelling).
• compartment syndrome → in the abdomen, →renal
impairment, gut ischemia and cardiac and pulmonary
complications.
• In the extremities, compartment syndrome can cause
pain, reduced capillary refill and par aesthesia.

CLINICAL FEATURES
• After about 3 weeks
– The burned(eschar) separates
– Scar tissue formation
– Contracture causing pain
– Limitation of movement
• Long term clinical features
– Amputation may be necessary
– Psychosocial factor
– skin change

Complications of burn
Early complications:
1. Shock: a. neurogenic
b. hypovolemic
c. septic
2. Toxemia: a. Acute toxemia
b. septic toxemia
3. Fluid and electrolyte disturbances
4. Injury to nerves and blood vessels
5. Retention of urine, in perineal burns
6. Pulmonary complications:

b. Inhalation injury of the tracheo-bronchial tree, due to
inhalation of fumes and also heat
c. Adult respiratory distress syndrome is a late complication
d. pneumonia, atelectasis are common among critically ill
patients
7. Urinary complications due to prolonged catheterization
8. Gangrene due to constricting eschars
9. Heart failure due to myocardial depression
10. Supra-renal failure due to septic shock
11. Hepato-renal failure
12. Abortion or Preterm labour

Late complications:
• Hypertrophic scar
more common after
spontaneous closure of
burns or healing of
widely meshed grafts
• Contracture: Grafts
and spontaneously
healing burns may
develop it.

Heterotrophic
ossifications :
Often occurs in joints
injured by burns or in
grafted or healed burns,
may show up months-years
after injury. Symptoms-
pain, limitation of mobility.
Acute gastrointestinal
ulcers
they appear as small,
circumscribed lesions
within the lining of the
stomach or duodenum.

Marjolin’s Ucer:
Squamous cell
carcinoma that can
occur in an area of
healed or grafted
burns.
• Psychological upset,
up to mania
• Disfigurement due
to scars and keloids
● Bone and joint problems.

BURN SIZE
• Burn size is determined by estimating the percentage of
the patient’s body surface area that is covered by partial-
thickness and full thickness burns.
• First-degree burns are not incorporated into formal
estimations of burn size.
• The “rule of nines” diagram is helpful for rapid assessment
of burn size, but this method is less accurate than the
Lund-Browder classification, especially in children.

BURN SIZE CONTD..
• The hand is often used to measure small burn areas; it
correlates to 1 percent of total body surface area.
• Studies have shown that the adult hand is closer to 0.8
percent of total body surface area, and that a child’s hand
is about 1 percent
• Hence, the Lund-Browder classification can be used for
initial assessment of burn size in adults or children

RULE OF 9" S IN ADULTS
• The “Rule of 9’s” is commonly used to estimate the
burned surface area in adults.
• The rule of nine splits the body into 12 sections: 11 of the
areas are each allocated 9% ( or multiples of 9) and the
groin region is given 1 %.
• The outstretched palm and fingers approximates to 1% of
the body surface area.
• If the burned area is small, assess how many times your
hand covers the area.
• Morbidity and mortality rises with increasing burned
surface area. It also rises with increasing age so that even
small burns may be fatal in elderly people.

RULE OF 9"S IN CHILDREN
• The ‘Rule of 9’s’ method is too imprecise for estimating
the burned surface area in children because the infant or
young
child’s head and lower extremities represent different
proportions of surface area than in an adult
• Burns greater than 15% in an adult, greater than 10% in a
child,
or any burn occurring in the very young or elderly are
serious.

LUND AND BROWDER CHART
• The Lund and Browder chart is the more accurate of the
two methods because it takes into account the change in
body proportion relating to age (eg; children have
relatively larger heads than adults).
• According to Lund and Browder chart-modified versus
original: a comparative study of 2019, the result showed
more consistency using modified LB chart than original LB
chart. In MLB chart, once the burn area is indicated,
counting of squares and division by 4 is easy and requires
no processing of fractions.

Immediate Management
❖ Stop the burning process
● remove the patient from source of injury
● if on fire stop, drop, cover face and roll
● remove hot, scalding or charred clothing
● if electric burn then first turn off the electric supply as
appropriate.
● if chemical burn remove all clothing then brush
powered chemical off the wound

❖ Cool the burn
● cold running water tap for at least 20 min
● ideal water temp. 15 c
● cooling effect up to 3 hours after injury
● keep the remaining area dry to prevent from
hypothermia
● if body temp. lower than 35C then stop cooling

Note
● irrigation of electric burn is not appropriate
● chemical burn require longer period of irrigation with
coupes water
● never neutralize an acid with a base or vice versa

first aid treatment for burn injuries Cuttle L and Kimble RM volume 18 NO.1.
2010

what not to do
● Don't commence first aid before ensuring your own
safety
● Don't apply paste, oil, or raw cotton
● Don’t apply ice
● Don't open the blisters with needle or pin
● Don't apply any material directly to the wound as it
might become infected
● Avoid application of topical mediaction until the patient
has been placed under appropriate medical care

Seek medical advice:
if burn is over 10% of BSA for adults and 5% of the body for
children or when there are associated trauma or concern
● plastic cling wrap is an appropriate simple dressing for
transferring patient with burn injuries to a special list
burn unit.

Assess
ABCDEF approach
● Airway maintenance with cervical spine protection
● Breathing and ventilation
● Circulation and cardiac status with hemorrhage control
● Disability
● Exposure: preventing hypothermia

● Fluid resuscitation
➔ appropriate with a burn greater the 15% BSA in adults
and more than 10% in child
➔ choice of Fluid : Lactate Ringer (LR)
➔ Parkland formula: 4ml* % of burn BSA * wt in kg
➔ half of this volume ;first 8 hour and second half in
subsequent 16 hour

Best clinical guidelines effective skin and wound management of non complex injuries
2014

2. Acute or intermediate phase of burn
care
•This phase follows the emergent /resuscitative phase and
begins 48 to 72 hrs after burn injury.
During this phase attention is directed towards:
•Extensive monitoring and continued assessment of
respiratory and circulatory status
•Hemodynamic stabilization
•Infection prevention
.Burn wound care
•Pain management
•Nutritional support

Preventing infection
•The burn wound is an excellent medium for bacterial
growth and proliferation.
•Systemic antibiotics are administered when there is
documentation of burn wound sepsis or other positive
cultures such as urine, sputum, or blood.
Wound cleaning
Tap water alone can be used for burn wound
cleansing. The temperature of the water is maintained
at 37.8°C (100°F).
—
performed at least daily in wound areas that are not
undergoing surgical intervention.

Topical Antibacterial Therapy
—
The three most commonly used topical agents are
silver sulfadiazine (Silvadene), silver nitrate, and
mafenide acetate (Sulfamylon).
—
This does not sterilize the burn wound; it simply
reduces the number of bacteria so that the overall
microbial population can be controlled by the body’s
host defense mechanisms.

Wound Dressing
—
When the wound is clean, the burned areas are patted
dry and the prescribed topical agent is applied; the
wound is then covered with several layers of
dressings. A light dressing is used over joint areas to
allow for motion.
Wound debridement
Tissue contaminated by bacteria and foreign bodies
should be removed thereby protecting the patient from
invasion of bacteria by any means
natural, mechanical or surgical means

Pain management
—
The patient’s pain level must be assessed throughout
the day because each type of pain is different and
various pain management strategies may be needed to
address different types of pain.
—
Opioid administration via the intravenous (IV) route,
particularly in the emergent and acute phases of burn
management, remains the mainstay for pharmacologic
management of burn pain.

Nutritional Support
—
Weight loss from fluid mobilization usually starts within
3 to 4 days post-resuscitation.
—
The adult burn patient may require 3,000 to 5,000
calories or more per day.
—
Supplement meals with between-meal high-protein,
high-calories. supplement vitamins and minerals.
High protein diet is recommended.

Surgical Management
Indications for surgery:
• Full thickness injuries.
• When the wound is unlikely to heal within 3 weeks, for
the risk of hypertrophic scar and contracture formation.
Aims of surgery:
1. Achieve wound closure
2. Prevent infection
3. Re-establish the function and properties of an intact skin
4. Reduce the effects of burn scar causing joint
contractures
5. Reduce extent of a cosmetically unacceptable scar

Escharotomy
• Escharatomy is technique in which incisions through the
eschar is done until the tissue gapes.
• It is done to release the pressure particularly on the
vascular supply.
• It is needed because inelastic eschar may interfere in
circulation causing compartment syndrome.

Management continu..
• Wound closure
After the eschar has been excised, the wound must be
closed.
• Goals:
❖ To prevent bacterial invasion and loss of evaporation.
❖ To provide durability, pliability and acceptable cosmetic.
It can be done by:
1. Skin grafts
2. Skin flaps

Skin graft
• A skin graft is the transportation of skin from one area
of the body to another.
• A graft is an area of skin that is separated from its own
blood supply and requires a higher vascular recipient
bed in order for it to be successful.
1. Autograft (split skin graft) (own skin)
2. Allograft (donor skin)
3. Heterograft or Xenografts (animal skin)
4. Cultured skin
5. Artificial skin

Skin Flap
The difference between a skin graft and a skin flap is
that it has its own vascularity, so can be used to take
over a wound bed that is avascular.
(Glassey 2004)

AIMS IN ACUTE AND SUB ACUTE PHASE

Role of the Physiotherapist in the
Rehabilitation of the Acute Burn
Patient
.Aims:
• Reduce pain
• Reduce risk of complications like contractures
and edema, particularly where it poses a risk for
-Impinging on peripheral circulation or airways
-Predisposition to contractures
• Prevent deformities/loss of range of motion
• Protect/promote healing

Common treatment techniques:
• Breathing exercises( Pursed lip Breathing, DBE,
Chest expansion exercises, Incentive spirometry)
• Rhythmic breathing exercise
• Immobilisation
o Bed rest
o Splinting
• Positioning
• Edema reduction techniques
• manual techniques of chest physiotherapy like
percussion and vibration
• suction(if necessary)

Immobilisation
• Rationale :
1. Protection
2. Promote Healing
3. Prevent deformities
4. Maintenance of range of motion
5. Prevention of contractures
(Immobilisation is incorporated with positioning,
splinting & ROM exercises in non harming
manner.)

TENS evidence for burn pain
• Effect of a combined continuous and intermittent transcutaneous electrical nerve
stimulation on pain perception of burn patients evaluated by visual analog scale: a
pilot study, Irma Pérez-Ruvalcaba et al 2015
• Summary:
• Objective: Assess effect of continuous and intermittent TENS on the perception
of pain in burns of different types.
• A pilot study was conducted in 14 adults with 2nd and 3rd degree burn. A VAS
was used to assess pain. Scale was graded from 0 “no pain” to 10 “maximum
pain” for assessing pain intensity before and after receiving the electrical
stimulation therapy. The electrotherapy sessions were performed 3x/week for 4
weeks. Each session had a duration of 30 mins. Four self-adhesive electrodes
were positioned according to the location of burn. A significant pain reduced
perception was reported (8.0±1.7 vs 1.0±0.5; P=0.027) by all patients after
electrical stimulation therapy.
• Conclusion: Electrical stimulation could be a potential nonpharmacological
therapeutic option for pain management in burn patients.

Breathing exercises
● Pursed lip breathing
● Chest expansion exercises
● Incentive spirometry
● coughing technique
➔ breathing exercises started immediately after admission has shown
good prognosis for faster recovery
➔ improves arterial blood gases in patients and prevent further
respiratory complications
Malik SS, Tassadaq N. Effectiveness of deep breathing exercises and incentive spirometry on arterial blood gases
in second degree inhalation burn patients. J Coll Physicians Surg Pak 2019; 29(10):954-7.)
● Rhythmic breathing exercise during dressing changes reduce pain
intensity
rhythmic breathing exercise is done during dressing changes and for 5
mins more after that dressing change procedure.

Deep breathing exercises : evidences

Conclusion of the article
The tested group incorporated with breathing exercises
immediate after the admission had good prognosis for
recovery and went on to rehabilitation after just 4-5 days.
Whereas the group who got same exercises after 3 days of
admission took about 15 days for prognosis i.e slow
prognosis

Effectiveness of Deep Breathing Exercises and
Incentive Spirometry on Arterial Blood Gases in
Second Degree Inhalation Burn Patients (Summyia Siddique Malik
and Naureen Tassadaq Foundation University Institute of Rehabilitation Sciences, Islamabad, Pakistan)
After second degree inhalation burn, the main reason of
post-burn mortality and morbidity is pulmonary
complications, mainly pneumonia
Methods:
5-6 cycles of Inccentive spirometry (ISM) with prior steam
inhalation and nebulization as per treatment criteria.
this session lasted for 20-30 minutes daily for a period of 7
days
Conclusion:
Deep breathing exercises are more effective in improving

Rhythmic breathing
Bozorg-Nejad M, Azizkhani H, Mohaddes Ardebili F, Mousavi S, Manafi F, Hosseini AF. The Effect of Rhythmic Breathing on Pain of
Dressing Change in Patients with Burns Referred to Ayatollah Mousavi Hospital. World J Plast Surg 2018;7(1):51-57.
•Training was done as follows:
(i) Close your eyes,
(ii) Relax the body muscles,
(iii) Breath slowly and regularly and uniformly (Inhale,
exhale, relax), so that breath in the air from your nose and
then breathe out slowly through your mouth, and
(iv) At all times of breathing, pay attention to the increased
size of the chest, the movement of your abdomen and
shoulders.
•Dose : patients were asked to do rhythmic breathing
during the dressing change that usually takes 10 minutes.
Then a maximum of 5 minutes after leaving the dressing
room

Mechanism
•According to gate control theory, when the input from descending
and inhibitory fibers of brain was more than stimulus input of small
fibers, the gate is closed and the pain data cannot be passed.
Accordingly, relaxation can reduce or complete remove the
pain through inhibitory impulses of the cerebral cortex and thalamus
and thus closing the gate.
Based on gate control theory, feeling out of control conditions can
cause opening the gate through the cerebral cortex and
increase different aspects of pain. As a result, burns patients need
to feel they have control over their position. For this purpose, learning
relaxation methods can create increasing feeling of personal control on
pain and hence patients can play active role in learning and implementing
pain management skills instead of being passive receiver of medical
interventions. Relaxation reduces pain and consequently anxiety
by releasing endorphins.

Positioning
• Contractile force after burn tend to draw the body into
fetal position(position of comfort) if this position is
maintained throughout healing leads to fixed
deformity.
• Anti-contracture positioning must start from day one
and may continue for many months post-injury.
• Positioning is important to influence tissue length by
limiting or inhibiting loss of ROM secondary to the
development of scar tissue.
• Fiona procter; Rehabilitation of burn patient; Indian journal of plastic surgery;
2010

Positioning continued...
Aim of positioning
❖ Reduce edema
❖ Maintain joint alignment while pt is immobilized
❖ promote wound healing
❖ relieve pressures
❖ protect new grafts/flaps
❖ prevent contractures

Positioning of hand
• The most common deformity associated with
burns is the ‘claw’ deformity.
• The position of safe immobilisation of the
burned hand is essentially the opposite of
the above claw deformity position.
• This position involves: 20-30 wrist extension,
80-90 degrees flexion MCP joints, full
extension PIP and DIP joints and palmar
abduction of the thumb.

Positioning according to burn areas

Splinting
• Highly effective method of helping prevent and manage burn
contractures and are an integral part of a comprehensive
rehabilitation programme.
• Splinting helps maintain anti-contracture positioning particularly
for those patients experiencing a great deal of pain, difficulty
with compliance or with burns in an area where positioning
alone is insufficient.
• It is the only available therapeutic modality that applies
controlled gentle forces to soft tissues for sufficient lengths of
time to induce tissue remodelling.
• Therefore, early application of splints to prevent the
development of post-burn scar contracture in the acute stage is
essential.
• Fiona procter; Rehabilitation of burn patient; Indian journal of plastic surgery; 2010

Continued
❑ Burn injury is a complex trauma that results in release of
burn toxin which in turn causes inflammatory response that
results in localized and generalized edema.
Dale wesley edgar, local and systemic treatments for acute edema after
burn injury: a systematic review of the literature ;2011

Continued
▪ Edema fluid in the extravascular space around the wound limits
the flux of toxic metabolites .
▪ Also limits the exchange of vital nutrients between circulation
and damaged tissues.
• Dale Wesley Edgar, Local and Systemic Treatments for Acute Edema After
Burn Injury: A Systematic Review of the Literature ;2011

Edema prevention
1. Elevation
- Elevation of the part above heart level is the most simple and
effective ways to prevent and decrease oedema .
- A Bradford sling can be used to facilitate elevation that facilitates
both elevation and protection of wound area .
Aoife Hale; Physiotherapy in Burns, Plastics and Reconstructive Surgery ;2013

Continued
• Following precautions should followed in case of severe burns :
- Elevation of the head.
- Elevate all limbs effected .
- Feet should be kept at 90.
- Neutral position of hips .
Aoife Hale; Physiotherapy in Burns, Plastics and Reconstructive Surgery ;2013

Continued
• Coban
- Coban wrap can be used to decrease oedema.
- It does not stick to underlying tissue, making it suitable for use
in the acute stages of burns .
( Lowell et al 2003)
Aoife Hale; Physiotherapy in Burns, Plastics and Reconstructive
Surgery ;2013

Continued
• Oedema Glove/Digi Sleeve
- These are hand specific oedema management products.
- Their use is based on the principle of compression.(Latham and Radomski
2008).
- Aoife Hale; Physiotherapy in Burns, Plastics and Reconstructive Surgery ;2013

Continued
• Topical negative pressure
- uses controlled negative pressure using a vacuum device to
promote wound healing by removing fluid from open wounds
through a sealed dressing or a foam dressing .
- Sub atmospheric pressure i.e 125 mmHg

Evidence on negative pressure
Negative pressure wound therapy with instillation and
dwell for management of complex burn: A case report
and review of literature, Palo L Padilla et al,2018
Case of 68 years/male with 3 day old 3rd degree burn
spanning 46% of total body surface area (TBSA)
• PMH: Hypertension and severe anorexia
• BMI: 14
• Pt suffered a flame burn when his clothes caught a fire in
home furnace .He stayed in home for 2 days post
injury,refusing treatment. However, on day 3 he was
found to be excruciating pain with altered mental status.

Evidence
• Upon the initial presentation he was resusciated,
stabilized, and taken for emergency excision debridement
and grafting of burn scar.
• The pts critical status, impaired nutritional state and
infection burden warranted alternative therapy option
thus the team try to negative pressure wound therapy
with dwell time (NPWT-d) using KCL velcro.
• Therapy setting: 18 min dwell time, every 2.5 hrs with
pressure of 125 mmHg utilizing VASHE hypochlorous
solution.
• Conclusion: NPWT-d was useful adjunct in treating and
stimulating wound healing

Management at Subacute stage
Since during this phase, there is primary closure of wound,
scar remodelling and scar contraction, the aims of
physiotherapy are:
● optimise scar appearance
● Limit effects of scar contraction/prolonged positioning
on Range of Motion and function
● Address effects of prolonged bed rest.

Management at Subacute stage
(contd…..)
At subacute stage, the physiotherapy interventions mainly
consist of:
● Pressure Garment Therapy and Silicone Therapy
● Scar massage
● ROM and mobilisation techniques

Pressure Garment Therapy and Silicone
Therapy
These are effective at subacute stage in scar removal from
the skin.

Pressure Garment Therapy and Silicone
Therapy(Contd…..)

How does the pressure garment
therapy works?
Work in 2 ways
1. by collagen remodelling during the wound healing
process : the tight pressure restricts the blood flow and
therefore oxygen availability, to the scar which is
thought to accelerate the maturation of scar
2. constant pressure exerted on scar tissue forces collagen
fiber of new tissue to grow systematically and more in
line with normal pattern of healthy skin fibers

Evidence on pressure garment
Pressure garment therapy for preventing hypertrophic
scarring after burn injury: Isobel M Haris et al, 2020
• Hypertrophic scarring following burn injury affects 32 to
67% of people with burn, tends s to occur within 4 to 8
weeks post injury.
• Garment should be worn for 23 hours a day ( allowing
to remove for upto 1 hour for personal care), for an
average 12 to 18 months, depending on scar severity.
• 2 types of garments : Ready to wear and custom-made
garments
• Exact pressure is unknown but less than 15 mmHg and
more than 40 mmHg does not give required result

Scar Massage
• The Rationale for massage is given in the table below:

Scar Massage(Contd…..)
The massage techniques that can be used are:
● Retrograde massage to aid venous return, lymphatic
drainage, mobilize fluid
● Effleurage to increase circulation
● Finger and thumb kneading to mobilize scar and
surrounding tissue
● Skin rolling to restore mobility
● Wringing the scar to stretch and promote collagenous
remodeling
● Frictions to loosen adhesions.

ROM and mobilisation techniques
Early mobilisation helps to counteract the effects of
prolonged bed rest by avoiding deconditioning and possible
respiratory complications.
● Active Range of Motion:
Gentle AROM can be given depending on the need for
immobilisation.
● Passive Range of Motion:
Passive joint mobilisation can be given.
❏ Dose: These interventions can be given twice daily and
for sedated patients, PROM can be given three times
day.
Note: AROM or PROM are contraindicated if there is suspected damage to extensor tendon i.e. flexion motion
should be avoided absolutely to prevent extensor tendon rupture. Also, ROM is contraindicated 3-5 days post
skin grafting during immobilisation.

Early rehabilitation is
typically begun within 7
days of injury and in case
of skin grafting 5-7 days
of immobilisation period
is there and then the
rehab is begun.
The implementation early
rehab has shown to
improve and prevent
contracture and better
outcome in other phases
of rehab.
The rehabilitation
protocol is shown in the
flowchart.

Functional Rehabilitation of hand
● Can be given in the form of patient’s light self care
activities as tolerated by the patient.
● Emphasis should be given on intrinsic flexion of the
MCP joints and intrinsic IP joint extension, gross
gripping(i.e. composite flexion), maintenance of web
spaces and opposition of thumb.

Recent Advances
Conclusion:
The application of VR
coupled with analgesics
is safe and effective in
reducing pain in burn
patients’ dressing
change and
physiotherapy.
Hence, VR based
rehabilitation can also
be used during
physiotherapy for pain
management.

Recent Advances(Contd…..)
Although there are many
emerging technologies for burn
management but the best
recommendation for
developing countries setting is
through education programs
and strategies targeting
primary prevention, first aid
and early presentation.
Educational programs address
risk factors like storage of
inflammable liquids, especially
targeting children have shown
to reduce mortality.

MANAGEMENT AT CHRONIC STAGE
Since in chronic phase, healing process may continue for up
to two years (scar tissue remodels and matures). The aim
of physiotherapy are:-
- Restore strength
- Exercise tolerance and function
- Functional retraining
- Prevent complications

Contd…
In this chronic stage, PT interventions consist of
● Aerobic exercise
● Resistance training
● Psychological rehabilitation
● Maintaining ROM

Contd…
Aerobic capacity and muscular strength is diminished by the
following factors
● Prolonged bed rest necessary in the early recovery
process
● Hypermetabolism
● Impaired thermoregulation
● Inhalation injuries and compromised respiratory
function
● Psychological factors

Safety consideration for aerobic and
resistive training
❖ A minimum of six months to two years post burn before
initiation of programmes
❖ Adequate healing of wounds and medical stability .
❖ Monitoring of heart rate and blood pressure
❖ Manage the environment to minimise thermal stress
❖ Monitor SpO2 during exercise.
❖ Allow additional rest periods to allow SpO2 to return to
normal.

Aerobic and resistance training
Rationale
● Low cardiorespiratory endurance
● Aerobic capacity lower in adults and children of >15%
TBSA
● Reduced lean body mass, endurance and strength of
>30% TBSA
● Though protein metabolism begin to normalize 9-12
months post burn , patients are still found to have
significant strength and aerobic related functional
impairment at >2 years post burn

Aerobic training in chronic burn
❖ Participation in aerobic exercise is dependent on the patient and
wound status.
❖ Common types of aerobic exercise include walking, cycling and
jogging.
❖ Swimming must only be commenced once all wounds are healed

Initiating aerobic training
❖ A minimum of six months to two years post burn
before initiation of programmes
❖ Time frame of 6 months post burn was chosen based on
clinical experience because by this time paediatric
patients :
95% healed had the opportunity to return home

Precautions and Contraindications
❖ Post-operative instructions, consultant and
multidisciplinary team (MDT) advice should be followed.
❖ Period of immobilisation immediately following skin
grafting must be observed.
❖ Careful hand placement/position is important to avoid
shearing the wound.
❖ Donor sites are painful but not a contra-indication to
exercise
❖ The impact of overheating, and sweat on skin integrity
must also be considered.

NOTE: Some potential precautions to consider are
exposed tendons, flaps, reconstruction, regrafting, k-wires,
medical condition e.g. low Blood Pressure, infections, graft
fragility, related trauma i.e. fractures (#),heterotrophic
ossification (HO), peripheral neuropathy and wound
breakdown.

Exercise prescrptions
Frequency
❏ 3 times per week (De Lauteur et al 2007; Grisbrook et
al 2012)
❏ 5 times per week with children. (Przkora et al 2007)
Intensity
❏ 65 and 85% maximum heart rate(MHR)

Type
❏ treadmill training, whether walking or running.
Durations
❏ 12 weeks
❏ six week (Paratz et al, 2012)
❏ 20-40 minutes (Grisbrook et al 2012; De Lauteur et al
2007; Przkora et al 2007))

Evidences
Aerobic exercise training in modulation of aerobic physical
fitness and balance of burned patients:zizi m.ibrahim ali et al:J
Phys Ther Sci. 2015 May
purpose:determine the impact of aerobic exercise on aerobic
capacity, balance, and treadmill time in patients with thermal
burn injury.
Study group:Burned adult patients, aged 20–40 years (n=30),
from both sexes, with second degree thermal burn injuries
covering 20–40% of the total body surface area (TBSA), were
enrolled in this trial for 3 months.

Patients were randomly divided into; group A (n=15), which
performed an aerobic exercise program 3 days/week for
60 min and participated in a traditional physical therapy
program, and group B (n=15), which only participated in a
traditional exercise program 3 days/week. Maximal aerobic
capacity, treadmill time, and Berg balance scale were
measured before and after the study
Result: improvement in group A was superior to that in
group B. [Conclusion] The results provide evidence that
aerobic exercises for adults with healed burn injuries
improve aerobic physical fitness and balance.

Efficacy of 12-week Pulmonary Rehabilitation Program on Exercise
Capacity of Burned Children: A Randomized Control Study
Amal. M. Abd El Baky American Journal of Research Communication
:dec 12 2014
❖ purpose: to evaluate the therapeutic efficacy of 12 weeks of
pulmonary rehabilitation program with a treadmill on exercise
capacity of burned children
❖ Subjects:30 children from both sexes with healed partial thickness
thermal burns participated in this study .7-17 years with total body
surface area (TBSA) of 20-40 %.Patients were randomized to either
group A (control) who received their traditional physical therapy
program, or group B (pulmonary rehabilitation group) who
received in addition to traditional physical therapy program a
pulmonary rehabilitation program in the form of aerobic exercises
on a treadmill.

❖ The treatment was continued for 12 weeks at the
frequency of 3 times per week
❖ Conclusion: adding aerobic exercises to traditional
rehabilitation program is more effective in improving
exercise capacity of burned children rather than
performing traditional rehabilitation program alone,
which accelerates the return of the children to their
schools and perform their daily living activities

Resistance training in chronic burn
❖ Burn is associated with long term reductions of muscle
mass and strength , which can limit their ability to
perform activities of daily living and participate in
physical activity.
❖ It has been reported that physical dysfunction and
quality of life continue to be adversely affected up to
three years after the initial burn injury .
Paul M.Gittings
et al;2018
❖ Burn injury is associated with skeletal muscle catabolism
and weakness in both adults and children

Goals of resistance training
•To increase patient’s physical capability and independence.
•To increase protein synthesis and muscle mass and
strength .
•To improve patient quality of life.

Exercise Prescription
❖ Frequency: 3 times per week
❖ Intensity: 50-60% 3RM in week 1, followed by
progression to 70-75% for week 2-6(4-10
repetitions) and 80-85% in week 7-12 (8-12)
repetition
❖ Type: Free weights, elastic bands or patients
own body weight
❖ Time:12 weeks (Suman et al; 2001)
: 6 week for pediatric burn patient
(Robert P Clayton et al; 2017)

Effects of resistance training
❖ The resistance training increases both lean and body
mass in both children and adults.
Eric Rivas Phd
et al;2018
❖ Resistance training causes an acceleration of protein
synthesis on cellular level by predominantly increasing
the amount of contractile proteins, which improves
muscle size and force output.
❖ Resistance training increases muscle tension which
initiates skeletal muscle growth, therefore affecting
LBM.
Grisbrook
et al; 2013

Contd…
❖ Exercise training improves muscular strength, muscular
and cardio-respiratory endurance, body composition
and flexibility in children and adolescent
Disseldrop et al;2011
❖ The effectiveness of resistance training is influenced by
multiple factors, including age, maturation, sex, and the
frequency, duration, and intensity of the training.
Eric Rivas, PhD et al; 2018

Precaution
❖ Vital sign should be monitored while performing the
exercises.
❖ Spo2 and RPE should be monitored in those at a risk of
reduced pulmonary function post burn during exercise.
❖ Eccentric exercise are not performed because they
have high potential to cause delayed onset of muscle
soreness.
❖ Caution should be use when performing exercise in
areas involving exposed tendons.

How do orthoses help in burn
management?
● 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.
● Types of splinting materials used: thermoplastics, plaster of
paris,etc.

Indications differ with
different stages of
rehabilitation
Acute phase
Wound healing phase
Rehabilitation phase
Reconstruction phase

Acute phase
Uses of splints:
● Prophylactic role if
tendons and joint
damage is
suspected.
N.B.:
● Because of the
fluctuating edema at
this phase, splints
should be
modulated and not
constrictive.

Wound healing phase
Uses :
Prevent development of
contracture.
Protect newly applied skin
graft.
N.B:
Avoid interference with
healing by proper fitting
-proper length
-Egdes rolled and flared
away from skin.

Rehabilitation phase
Uses:
Reduce contracture non-
surgically.
Prevent deformities
Provides sustain stretching
of scar tissues.
Maintain gained ROM
N.B:
If scar tissue tensile strength
is poor monitor for wound
break down.

Reconstructive phase
Uses:
For fixation following release
of contractures or
reconstruction surgery.
N.B:
Monitor for wound
macaration.

What types of orthoses are used in
burns management?
1. Static splint :
● Mostly used splint for burn injuries.
● No movable parts
● Immobilizes area following skin graft

2. Dynamic splint:
● Movable parts allowing joint movement
● Apply a low-load, prolonged stress that can be adjusted
to a patient’s tolerance.
● Oﬀer great potential for correcting a developing
contracture and the early return of active function in
areas of extensive burn and grafting.

Precautions :
● Routinely checking splint
● Maintaining hygiene.
● Pressure points, skin breakdown, edema.
● Circulation
● Environmental issue

Splints for neck
The splints are designed to accomplish three goals of equal
importance:
1. Keep the neck extended.
2. Mould the neck-chin angle.
3. Apply even pressure on the grafted area.

● Flexion neck deformities:
Flexion deformities of the neck can be minimized with
thermoplastic neck splints, Watusi collar, manually
fabricated splints, and pre-fabricated splints such as the
Philadelphia collar have been used for the management
of scar contractures

Postburn Contracture of the Neck--Our
Experience With a New Dynamic Extension
Splint
S Bhattacharya1, S K Bhatnagar, R Chandra
● Plaster of paris static splint supporting the inferior
margin of the mandible superiorly, rounded holds on
the shoulder on either side was applied for 4-6 weeks
after skin graft.
● The sun ray dynamic extension splint replaced the
static splint 4-6 weeks after surgery and since it allows
nodding, talking and eating with little pain in the upper
back and neck it was highly accepted by patients. This
was worn for 20 months.

Alternative Splinting Methods for the Prevention
and Correction of Burn Scar Torticollis Michael A.
Serghiou, OTR, Alex McLaughlin, OTR, David N.
Herndon, MD
● Dynamic Antitorticollis Strap may be applied immediately after burn
without compromising wound healing or disturbing grafted sites on
the neck or chest areas.
● It is applied for patient who are bedridden and
discontinued when the patient gets out of bed for the performance
of activities of daily living or exercise.

● The antitorticollis neck splint is used in the
rehabilitation phase and can be serially adjusted to
correct lateral flexion contractures of the neck.
● The combined use of these devices during the scar
maturation phase provides therapists with alternatives
in preventing burn scar torticollis.

Use of an Improved Watusi Collar to Manage Pediatric Neck
Burn Contractures K. Hurlin Foley, OTR, BCP, B. Doyle, PT, P.
Paradise, I. Parry, MSPT, T. Palmieri, MD, D. G. Greenhalgh, MD
● Rigid splints used for scar management can limit active
range of motion, resulting in significant impairment of
functional mobility and activity performance.
● Can be use 2 weeks after neck grafting or at wound
closure.
● The collars are worn 23 hours per day unless the
patient experiences discomfort during sleep.
● In addition to collar use, patients continue standard
range of motion (ROM) exercise and massage during
the scar maturation phase.

• The lifespan of the collar is approximately three months
when used continuously and washed daily.

Splinting and orthosis for face and
mouth
- Burns of face- can affect eyes, eyelids, contours of face,
soft tissues around mouth
Facial orthoses;
Function; to support the functional contours of specific
areas of face
● Helps decrease scar hypertrophy
● Minimize or prevention of eversion deformity of
lower eyelids and lips

Transparent Face Orthoses
● Custom made mask made from clear plastic
● Made from a model of clients face
● Fitted directly against the skin
Function;
● Protect fragile maturing of scar tissue from irritants and
unwanted shear forcces that could impair healing process
Prescription; 20- 23 hrs daily frm 6 mnth to 2yrs

Orthoses for mouth
- Contracture of mouth after burn is particularly
troublesome- Microstomia
❖ abnormalities of oral symmetry, speech & dentition
❖ psychological problems; functional inability in
feeding, limitations in dental care
❖ increased incidence of dental decay
- Variety of mouth orthosis available(
prefabricated or custom made)

Microstomia preventing orthoses
Objectives; to apply force on the maturing scar
➔ To prevent contractures of lip and buccal tissues
➔ To help maintain the symmetry of oral stoma
◆ by positioning each commisure from midline
equidistant from midline of lips and by
stabilizing the orbicularis oris muscle by two
point fixation
➔ To adequately functioning lips
➔ To ensure stable and longlasting results

Contracture affects actual opening of mouth
● Cone shaped splints - to increase opening of
mouth
● narrower portion of of cone are cut off as
mouth able to open wider
● Patient progresses to a wider part of spliny to
widen opening of mouth
@orthotics and prosthetic in rehabilitation by michael m.

Static orthoses;
● have no movable parts once in place
● the pressure exerted by the device can be adjusted only
through serial splinting or basic structural alterations
Dynamic orthosis;
● Permit adjustments to accomodate changes that may
occur in commissureal dimension
● provide the external forces either intraorally or
extraorally

General advantage over static appliances;
● the pressure exerted by the deviceis adjustable and will
permit progressive controlled tension.
● Alterations to dynamic orthoses do not require basic
structural changes to the appliance
Wearing schedule; worn all the time when pt not
eating or receiving oral care or is speaking

Dynamic othoses names and features

Novel Use of Orthosis in a Case of Burn
Contracture MicrostomiaS. @ V. Soumya; 2016
Procedure; Post bilateral commisuroplasty static orthosis
Static orthosis with vertical component
force
Dynamic orthosis
● 3wks immediately after surgery; static orthosis
● After 3 wks ( once thickening and contraction of scars);
dynamic orthosis

Result
Conclusion; The use of both static and dynamic orthosis in
appropriate sequence resulted in good scar outcome.

Orthosis for Upper Extremity
Finger extension splints for burns
Purpose: to support a finger joint so that it heals
without contracting and to prevent deformity
Wearing Schedule: varies; a common schedule would
be to wear it at night while resting and take it off during
the day for exercise and activity

Resting hand splint for burns
Purpose: to support the hand and wrist joints so that they heal
without contracting and so that a deformity does not develop.
Wearing Schedule: varies; a common schedule would be to
wear it at night while sleeping and take it off during the day for
exercise and activity.

Interdigital (between fingers) inserts for burns
Inserts for between fingers and thumb web space
Purpose: to prevent the skin from shrinking as it heals and to
restore range of motion by stretching the skin
Wearing Schedule: usually full-time under compression gloves

Clavicle strap for burns
A strap for the shoulders
Purpose: to prevent the skin from shrinking as it heals
and restore motion by stretching the skin
Wearing Schedule: varies; may be part-time or full-time, often used
to help hold an axillary splint in place

Airplane or axillary splint for burns
Splint for the shoulders or axilla
Purpose: to prevent the skin from shrinking as it heals and to
restore motion of the shoulder by stretching the skin.
Wearing Schedule: varies; may be part-time or full-time

3D Printed soft material finger extension splints
(A) Post burn mallet finger deformity caused by extensor tendon injury. (B) Conventional plastic
static splint. (C, D) Threedimensional printed soft material finger extension splint design

3D Printed hard material finger extension splints
(A, B) Post burn claw hand deformity caused by ulnar nerve injury. (C, D) Three-dimensional
printed hard material finger extension splint design

ORTHOSIS FOR LOWER EXTREMITY
HIP
Anterior Hip spica
Purpose:to correct hip flexion contracture
Position: Neutral alignment,10-15°abduction ,slight extension

KNEE
Knee extension splint
Purpose:to prevent flexion contracture of popliteal fossa
Position: position in extension with no rotation
Wearing schedule: 2 hrs on 2 hrs off during day

Knee extension device is commonly used during intermediate stag
,at night while mobility is encouraged during day

ANKLE
Ankle equinous is the most common type of ankle contracture
following burn injury.
Some examples:
● Prefabricated splints
● Custom made thermoplastic foot drop splints
● Ankle foot orthosis
● Rocker bottom shoes

Purpose:
● to maintain properpositioning of ankle
● To prevent contracture and foot drop
Position: 90°dorsiflexion , with no inversion/eversion
Wearing Schedule: usually when in bed or in the chair. May
have an on and off schedule throughout the day.
Splinting should be done at night at intermediate stage and
exercise during day

• Paul m gitting et al" resistance training for rehabilitating
after burn injury: A systematic review and metanalysis";
Elsevier, volume 44, issue 4, June 2018; Page 731-751
• Rivas PhD et al; "Burn injury may have age-dependant
effect on strength and aerobic incapacity in males";
Journal of burn care and research , volume 39 ,issue 5,
Sep/Oct 2018
• Ho-Sung Nam et al. "The application of three-dimential
printed finger splints for post hand burn patients: a case
series investigation; Annals Rehabilitation medecine;
2018

Complication of burn
1.Shock:
➢ Hypovolemic
➢ Neurogenic
➢ Septic
2.Fluid and electrolyte disturbances
3. Injury to nerves and blood vessels
4.Pulmonary complication:
➢ Acute respiratory obstruction(upper respiratory
obstruction)
➢ Inhalation injury of tracheo-bronchial tree , due to
inhalation of fumes and also heat.
➢ Adult respiratory distress syndrome is a late complication.
➢ Pneumonia, atelectasis are common among critically ill
patients.
5. Urinary complication due to prolonged cathetarization.

6.Gangrene due to constricting eschars.
7.Heart failure due to myocardial depression
8.Supra renal failure due to septic shock
9.Hepato - renal failure
10. Abortion or preterm labour.
Late Complication:
● Disfigurement due to scars and keloids
● Contracture of joints
● Chronic ulcer that may be complicated by malignancy
● Psychological upset, up to mania.

SCAR TISSUE
● Scar are fibrous tissue that forms on skin after wound,
injury to surface of skin or as a result of surgical
intervention.
● Disruption can form any external or internal type of
injury any of these phenomena can damage cells ,
leading cascade of events that culminates in formation
of collagen fibres that bind up and tie together out of
broken pieces.

AIMS
● SHORT TERM GOALS
➢ To reduce pain and discomfort
➢ To control and treat problematic scarring
➢ To prevent infection (universal precaution)
● LONG TERM GOALS
➢ To improve function
➢ To prevent contracture
➢ To prevent disabilities

Types
Burn can cause one of these kind of scars:
● Hypertrophic scars
● Contracture scars
● Keloid scars
Arun Goel et.al; Post Burn Scars and Scar Contractures; Indian Journal of Plastic Surgery,2010

Hypertrophic scar
● Pale brown in colour, not painful, not tenderness
● Raised - excessive collagen deposit
● Due to deep dermal burns
● Limited to scar tissue only

Keloid scar
● Raised, shiny, flesh coloured, pink or red
● Hard, hair less
● Continues to grow larger over the time

Contracture scar
● It is tightening of the skin after 2nd or 3rd degree burn.
● Surrounding skin begins to pull together resulting in
contracture.
● Restrict ROM.

Objective of Scar tissue management
•To control and treat problematic scarring
•To prevent contracture and improve function
•To reduce pain and discomfort
•To improve cosmetic outcome
➔ Aim for scarring to be soft, flat, pale, pain free and itch
free and the individual to have returned to as close to
their normal level as function as possible.

Considerations when selecting
treatment
•Severity of scar
•Location and size of scar
•Length of time to heal
•Number of risk factors, e.g. previous problematic scarring
•PMH
•Allergies
•Age
•Lifestyle of patient

Considerations when selecting
treatment
•Functional and cognitive ability of patient and available
support network
•Patient preference
•Ability to attend appointments
•Cost

Myofascial release
•Deep transverse friction massage, also known as Cyriax
deep transverse massage helps to release non physiological
evolution of scars.
•Instrument-assisted soft tissue mobilization IASTM uses
specially designed instruments to provide a mobilizing effect
to scar tissue and myofascial adhesions.

Kinesio-taping
Advantages:
➔ Reduces mechanical tension acting on
scars while facilitating desires muscle
and fascial release.
➔ Reduces inflammation and increases
lymphatic flow
➔ Provide a low intensity, long duration
stretch to the tissues around the scar
tissue which helps to slowly stretch out
the collagen cells that make up the scar.
Disadvantages:
➔ Requires reapplication
➔ Scar can be fragile and may not be able
to tolerate for long period.

Silicone gel / sheeting therapy
•Silicone sheets and silicone gels are universally
considered as the gold standard in scar management.
•The advantages of silicon gel include easy
administration, even for sensitive skin and in children.
•It can be applied for any irregular skin or scar surfaces,
the face, moving parts (joints and flexures) and any size
of scars.
•It increases hydration of stratum corneum and thereby
facilitates regulation of fibroblast production and reduction
in collagen production. It results into softer and flatter
scar. It allows skin to "breathe".

Silicone gel / sheeting therapy
•It protects the scarred tissue from bacterial invasion and
prevents bacteria-induced excessive collagen production in
the scar tissue.

Pressure therapy
•Pressure garment is made up of specially
designed fabric called power net.
•Pressure therapy uses compression
dressings to deliver mechanical pressure to
the scar, reducing capillary perfusion
pressure and accelerating collagen
maturation, with the goal of flattening the
scar.
•Average pressure applied is 15-25 mmHg.

Ultrasound therapy
•The waves generated by ultrasound cause tiny
vibrations in the cells of the soft tissues. These micro-
vibrations affect the fibers that form scar tissue.
• Over time, ultrasound used in this method can prevent
scar tissue from forming and may be able to break scar
tissue down.
•As with its thermal effects, ultrasound used to break up
scar tissue can also maintain and increase range of
motion.

Cryotherapy
•Intralesional (IL) cryotherapy is a novel
treatment technique for keloid scars, in
which the scar is frozen from inside.
•Effective for volume reduction and
alleviation of pain and pruritus.
•By using a hollow needle, a cryogen can
be applied directly into the deeper dermis
of the scar.
•Only 2 devices are currently commercially
available: a liquid nitrogen-based device
and an argon gas–based device.

Splints
•During the inflammatory and early fibroblastic stages of
healing, splints are used to immobilize injured tissues to
promote healing.
Affected joints or regions must be splinted in positions of
function to avoid contractures
Influence of splints on healing tissue
; 1998

Neurocognitive approach
•Relaxation strategies
•Expressive writing
•Hypnosis
➔ The effects of stress on the alteration of inflammatory
parameters, through the mediation of the hypothalamic–
pituitary–adrenal (HPA) axis.
A multidisciplinary apporach to
scars ; a narrative view ; 2015

Scar management Guideline
Updated Scar
Management
Practical
Guidelines:
Non-invasive
and invasive
Measures; 16
April 2014

Introduction
● The transfer of a section of skin, of variable thickness and
size, which is completely detached from its original site
(donor area) and moved to cover the zone to be repaired
(recipient area).
● Skin grafts are a valuable option for the closure of wounds
that cannot be closed primarily.
Berlin et.al; Skin Grafting In Wound Healing and Ulcers of the
Skin; Springer 2005.

Classification
1.On the basis of thickness of explant

2. On the basis of origin of explants

Types of skin graft
1.Sheet graft
● Sheet graft is piece of donor skin
harvested from an unburned area of the
body.
● The size of the donor skin is about the
same size as the burn wounds.
● The donor sheet is laid over the cleaned
wound and stapled in place.
● Used in cosmetic areas of the body (face,
neck, hands).

2. Meshed graft
● In a meshed skin graft, the skin from the donor site is stretched to
allow it to cover an area larger than itself.
● Meshing allows blood and body fluids to drain from under the skin
grafts, preventing graft loss, and it allows the donor skin to cover a
greater burned area because it is expanded.
● Meshing involves running the donor skin through a machine that
makes small slits that allow expansion similar to fish netting

Indication
-Acute skin loss. Eg:flame burns,frictional burn.
-Chronic skin loss.eg:chronic leg ulcers.
-Adjunct to some procedure.eg:scar excision.
-Miscellaneous indication.

Contraindication
-Absolute contraindications include:
- incomplete removal of cancer
- active infection, uncontrolled bleeding.
-Relative contraindications include :
-Smoking, an anticoagulant medication, bleeding disorder
- chronic corticosteroids, or malnutrition.

Complication
● Adherence of graft to underlying tissues.
● Contracting scar tissues.
● Decreased range of motion.
● Hard immobile tissues.
● Increased redness.
● Graft Failure.
● Discomfort of tight skin.

Technique
● Donor area: Commonly thigh, occasionally
arm, leg, forearm.
● Knife used is Humby’s knife.
● Blade is Eschmann blade, Down’s blade.
● Using Humby’s knife graft is taken, punctate
bleeding is observed which says that proper
graft has been obtained.
● Donor area is dressed and dressing is
opened after 10 days,not earlier.
● Recipient area is scraped well and graft is
placed after making window cuts in graft to
prevent the development of seroma.
Humby’s knife.

-Graft is fixed and tie-over dressing is placed. If graft is
placed near the joint, then the part is immobilised to
prevent friction which may separate the graft.
-On 5th day, dressing is opened and observed for graft
take up.
-Mercuro chrome is applied over the recipient margin to
promote epithelialization.
SRB Manual of Surgery 5th edition

Stages of Graft Intake
1. Stage of plasmatic imbibition: Initial graft ischemia (24-
48hrs).Thin, uniform, layer of plasma forms between recipient bed
and graft.
2. Stage of inosculation: Fine vascular network and new blood
vessels begin growing(48hr). Capillary buds make contact with
graft and blood flow is established.
3. Stage of neo-vascularisation: New capillaries, fibroblast
proliferate into graft. Combination of old and new vessels and
collagen linkages.
Ref: SRB Manual of Surgery 5th edition

Management of donor site
1. Split thickness skin graft donor site:
● Application of pressure garments to prevent hypertrophic
scar
● Massage with a topical lubricant after(5-10 days of
epithelialization has occurred)
1. Full thickness skin graft donor site:
● Suture are removed at 7 days
● Masssage may be initiated 2-3 days after, suture removal
to help soften
● Application of pressure garments

1. Pressure Garment Therapy (PGT):
● As for the skin grafts, PGT helps to protect newly healed
skin/grafts.
● Its main aim is to reduce scarring by hastening scar
maturation.
● For maximum effect, it is recommended to wear as early
as possible for 23hours, removing only for washing and
creaming of scars.
Aoife Hale et.al; Physiotherapy in Burns, Plastics and Reconstructive surgery; Impairment and Disability
Short Course, 19th April 2013, page 30-33, 50-58

2. Ultrasound therapy:
● use of ultrasound (0.5 W/cm2, applied for 5 minutes
in alternate days, started from 14th day to 21st days)
on skin injury healing is found to be effective.
3. Massage Therapy:
● physical therapy coupled with ultrasound massaging
can improve patients suffering from developing
deformities and thereby maintaining the skin integrity
forever.
Mohan Kumar G. et.al; Effectiveness of physiotherapy in skin grafting; TJRPC Vol. 2, Issue 2,
Dec, 2016, 33-38

4. Range of motion exercises are contraindicated till 5th
post operative day so as to to allow proper healing of
graft.
5. Limb should be elevated as edema puts a graft at
risk of poor adherence.
6. Early ambulation is indicated with skin grafting.
7. Splinting can be a supportive tool that can help
promote adherence of the skin graft.
Nedelec B. et.al; Practice guidelines for the application of nonsilicone or silicone gels and gel sheets
after burn injury; Jornal of Burn care and research May/June, 2015

Conclusion:
● North American burn surgeons
generally mobilize UE and LE
graft sites that do not cross
joints.
● When the elbow, wrist, knee,
or ankle is involved,
immobilization of the joint for 3
or 5 days is common practice.
● Ambulation protocols for the
LE generally align with the
guidelines set forward by
Nedelec et al10 in 2012 and
the randomized controlled trial
by Lorello et al12 in 2014.
Extremity Mobilization After Split-
Thickness Skin Graft Application A
Survey of Current Burn Surgeon
Practices
Helene Retrouvey et al.
Burn surgery and research,2019

Conclusion:
● Physical
therapy
coupled with
ultrasound
massaging
can improve
patients
suffering from
developing
deformities and
thereby
maintaining
the skin
integrity
forever.

Conclusion:
● Burn subjects who
are ambulatory
before autografting
can safely ambulate
on POD 1 without
fear of autograft
failure compared
with those subjects
who remain on bed
rest for 5 days.
● This first randomized
controlled trial will
help lend credence
to the safety of early
ambulation for
patients with LE
autografts.

Conclusion:
● An early
postoperative
ambulation protocol
should be initiated
immediately, or as
soon as possible,
after lower extremity
grafting unless any
exclusion criteria are
encountered.
● External compression
must be applied
before ambulation.
● If the graft crosses a
joint, the joint should
be immobilized
continuously until the
first dressing change.

FLAPS
● Any tissues used for reconstruction or wound closure
that retains all or part of its original blood supply after
the tissue has been moved to recipient location.
● The part that remains attached is pedicle or base.
● A flap that is detatched in order to transfer tissues is
called free flap.
● A flap has their own blood supply so can be used to
cover avascular defects.
● Skin flaps include the following tissues:
1.Bone without periosteum.
2.Tendon without paratendon.
3.Cartilage without perichondrium.

TYPES OF FLAPS
1)Local flap
I-t is transferred from site adjacent to the defect.
-It is used when the tissues is loose and direct closure of
donor site is possible.
2) Transposition flap
- A square of skin is raised and moved to adjacent defect

3) Rotation flap
-Semi circle of skin is raised and rotated to cover the defect.
4) VY adjacent flap
-This transfer of V shape of skin that is moved towards a Y
shaped closure.
-Used to cover finger tips injury.

5) Distant flap
-Area of distant places is flapped.
-Eg. Defect of hand covered by flap from areas of groin.
6) Myocutaneous flap
-Eg. Lattisimus dorsi muscle used in reconstruction
of breast.

Classification of skin flaps
A.Vascularity :
-Random pattern flaps
-Axial flaps
B. Anatomical composition:
-Skin flaps (epidermis + dermis + superficial fascia)
-Fasciocutaneous flap (skin flaps + deep fascia)
-Muscle flap (muscle belly without overlying structures)
-Myocutaneous flap (Muscle flap + overlying skin)

5. Osseous flap (bone)
6. Osseomyocutaneous flap (bone + muscle + skin)
7. Composite flap (no. of different tissues such as skin, fascia,
muscle and bone )
C. Methods of relocation:
-Local flaps
-Distant flaps

FLAP VS GRAFT
FLAP
● Can carry other tissues.
● Has its own blood supply.
● Better color take and less
likely to contraact.
● More adaptable to weight
bearing.
● Can be used on a bed with
questionable nutrition.
● Does not requires pressure
dressing.
● Can bridge defects.
GRAFT
● Limited to transplantation of
skin.
● Depends on recipent site for
nutrition.
● Cosmetic - may discolor or
contract.
● Less adaptable to weight
bearing.
● Less able to survive on a bed
with questionable nutrition.
● Requires pressure dressing.
● Cannot bridge defects.

REFERENCES
• Outpatient Burns: Prevention and Care EMILLIA C. O. LLOYD, et al
AAFP 2012
• Burns: Definition, Classification, Pathophysiology and Initial Approach
Garcia-Espinoza JA et al ,general medicine 2017
• Burn injury ,Mayo clinic 2012
• World health organization 2007
• Gerard M., Jennifer K. The Washington Mannual of Surgery.
21st edition, 2002. Lippincot Willims and Wilkins, USA.
• Williams NS, Christopher J.K, Bailey and Love’s short practice
of surgery.. 25th edition. Edward Arnold (Publishers) Ltd; 2008
• Black JM, Hawks JK. Medical and surgical nursing. 8th edition.
Philadelphia: Elsevier Publication; 2012
• CUtle L et al. first aid for burn injuries 2010
• Best practice guideline effective skin and wound management
of non vcompex burns 2014

• Joseph Prohaska et al; Skin graft ; Stat Pearl; 2020 april 30.
• Helene Retrouvey et al; Extremity Mobilization After Split-
Thickness Skin Graft Application A Survey of Current Burn
Surgeon Practices; Burn surgery and Research, 2019.
• Mohan Kumar G. et.al; Effectiveness of physiotherapy in skin
grafting; TJRPC Vol. 2, Issue 2, Dec, 2016, 33-38.
• Nedelec B. et.al; Practice guidelines for the application of
nonsilicone or silicone gels and gel sheets after burn injury; Jornal
of Burn care and research May/June, 2015.
• D.J. Lorello et.al; Results of a Prospective Randomized Controlled
Trial of Early Ambulation for Patients With Lower Extremity
Autografts; Journal of Burn Care & Research September/October
2014.

• Nedelec B. et.al; Practice Guidelines for Early Ambulation of Burn
Survivors after Lower Extremity Grafts; Journal of Burn Care &
Research320 Nedelec et al May/June 2012.
• Arun Goel et.al; Post Burn Scars and Scar Contractures; Indian
Journal of Plastic Surgery,2010.
• Berlin et.al; Skin Grafting In Wound Healing and Ulcers of the Skin;
Springer 2005.
• SRB Manual of Surgery 5th edition; Page no: 12-13; 321-322

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