Burns related to physiotherapy

1. Skin Anatomy
• Skin - largest organ of
the body
• Two distinct layers :
– Epidermis
– Dermis

2. Classification of burn injury

4. Electrical Burn
• Signs and symptoms of an electrical burn may vary
according to the type , intensity of current and area
of the body the electric current passes.
• Contact sites –
– first contact with electricity
– where patient was grounded
• Wound at initial contact – charred and depressed ,
skin appears yellow and ischaemic .
• Ground site – appears as explosion out of the tissue
at the site, dry in appearance.

5. • Consequences :
– Necrosis
– Blood supply to surrounding tissue and muscle
may be altered
– Cardiac difficulties : arrhythmias, ventricular
fibrillation.
– Respiratory arrest
– Renal failure – excessive protein breakdown and
shock
– Acute spinal cord damage , vertebral fracture.

6. Burn wound zones

7. Extent of burned area

8. Complications of burn injury
Infection
Pulmonary complications
Metabolic complications
Cardiovascular
complications
Heterotopic ossification
Neuropathy
Pathological scars

9. Dermal healing
• Inflammatory
phase
• Proliferative phase
• Maturation phase
Epidermal
healing
Burn wound
healing

10. Epidermal healing
• Burn injures just the epidermis.
• Stimulus for epithelial growth – presence of an open
wound exposing subepithelial tissue to environment.
• Intact epithelium covers an exposed wound through
mitosis and ameboid movements.
• Epithelial cells stop migration from when they are
completely in contact with other epithelial cells.
(contact inhibition).
• After this, cells begin to form various layers of
epithelium.
• Adequate nutrition and blood supply to be provided
for continuous migration and proliferation or else
new cells die.

11. • This process most evident in partial thickness burns
that has intact hair follicles and glands.
• Cells migrate outwardly from appendages
(epidermal islands)
• Damage to sebaceous glands cause dryness and
itching of healing wound.
• Skin may split .
• To teach lubrication and moisturizing cream
application to newly healed tissues.

12. Dermal healing

13. • Tissue deeper than epidermis, dermal healing
or scar formation occurs.
• Scar formation is divided into 3 phases :
– Inflammatory
– Proliferative
– Maturation

14. Medical management of Burns
• Initial management :
– Establish and maintain an airway.
– Prevent cyanosis, shock and hemorrhage.
– Establish baseline data on the patient, such as
extent and depth of burn injury.
– Prevent or reduce fluid loses.
– Clean the patient and the wounds.
– Examine injuries.
– Prevent pulmonary and cardiac complications.

15. • Hydrotherapy tanks or
whirlpool tubs have
some disinfectant in
water to assist in
infection control.
• Water temperature
should be 37o -40oC.
• Adherent dressing
removed.
• Converted to showers,
spraying or bed baths.

16. • Technique for applying
topical cream or
ointment.
– Open technique.
– Closed technique.
• Closed technique
consists of several
layers:
– First layer is
nonadherent.
– Followed by cotton
padding.
– Final layer consists of roll
gauze or elastic
bandages.

18. Surgical management of wound burn
• Primary excision – surgical removal of eschar.
• Patient taken to surgery within 1 week of injury.
• Burns wound closed with grafts.
• Types of grafts :
– Autograft
– Allograft
– Xenograft
• Advanced technique foe burns wound care is Skin
substitutes. Types of skin substitutes:
1. Cultured epidermal autografts (CEA)
2. Cultured autologous composite grafts
3. Allergic skin substitue
4. Cultured dermis (temporary)
5. Cultured dermis (definitive)

19. Skin grafting procedure
• Donor site.
• Wounds heal by re-epithelialization .
• Thinner skin graft – better adherence; thicker skin
graft – better cosmetic result.
• Sheet graft and mesh graft .
• Successful adherence – sufficient vascularity
within wound bed.
• Survival of skin graft depends on several factors:
– Circulation, nutritive supply to grafts.
– Inosculation.
– Penetration of host vessels into graft site.

21. Surgical correction of scar contracture
• If PT interventions are unsuccessful in averting
scar contracture formation, and limitation
noted in ROM and function, surgery may be
required.
• Z- plasty, serves to lengthen a scar by
interposing normal tissue in the line of the
scar.
• Skin grafts used for more severe contractures.

23. Physical therapy management
• Goals of physiotherapy treatment:
– Wound and soft tissue healing is enhanced.
– Risk of infection and complications is reduced.
– Risk of secondary impairments is reduced.
– Maximal ROM is achieved.
– Pre- injury level of cardiovascular endurance is restored.
– Good to normal strength is achieved.
– Independent ambulation is achieved.
– Independent function in BADL and IADL is increased.
– Scar formation is minimized.
– Patient, family, caregivers understanding of expectations and
goals and outcomes is increased.
– Aerobic capacity is increased.
– Self- management of symptoms is improved.

24. Positioning and splinting
• Started on day of admission.
• Outcomes of positioning :
1. Minimize edema.
2. Prevent tissue damage.
3. Maintains soft tissue in an elongated state.
• Splinting can be viewed as an extension of the positioning program.
• Indications for use of splints:
1. Prevention of contractures.
2. Maintenance of ROM achieved during an exercise session or surgical
release.
3. Correction of contractures.
4. Protection of a joint or tendon.
• Types of splints :
• Static
• Dynamic

29. Active and passive exercises

30. Resistive and conditioning exercise
• Burns patient lose body weight and lean
muscle mass.
• Exercises consist of isokinetic, isotonic or
other resistive training devices.
• Vitals to be monitored.
• Patients to be encouraged to participate in
exercises that stresses cardiovascular function
like walking, cycle ergometry, treadmill
walking, staircase climbing etc.

31. Ambulation
• Initiated at earliest appropriate time.
• Ambulation initiated after skin graft, lower
extremities should be wrapped in elastic
bandages (fig of 8) to support new skin grafts
and promote venous return.
• Orthostatic intolerance or pain in lower
extremities in a dependent position.
• Initially assistive device to ambulate.

32. Scar management

34. Follow up care