Burn and burn rehabilitation includes patho physiology of burn, types or causes of burn, acute management of burn, rehabilitation of burn, surgical management, grafting, complication of burn etc.

1. BURN REHABILITATION
DR. SHYAM SUNDER SHARMA
RESIDENT DOCTOR
PMR SMS MEDICAL COLLEGE, JAIPUR

2. INTRODUCTION
• A burn is the body’s response to a soft tissue
insult from an external agent, such as heat,
cold, chemicals, electricity, and radiation.
• 85–90% of burns are caused by heat.
• 10–15% of burns are from frostbite, chemical
and electrical damage.

3. Cellular Response to Burns
Local reactions to burns include:
a) Exposed collagen causes platelet activation.
b)Intense vasoconstriction secondary to
epinephrine, prostaglandins, serotonin, and
leukotrienes.
c) Within a few hours, histamine release causes
vasodilatation and increased capillary
permeability, allowing protein and albumin into
the extravascular space. This is followed by fluid
extravasation, which causes severe edema.

4. Cellular Response to Burns
d) Late capillary permeability secondary to
leukotrienes.
e) Swelling and rupture of damaged cells.
f) Platelet and leukocyte aggregation with clot
formation from tissue thromboplastin,
endotoxin, interleukin-1, and Hageman factor.
g) Establishment of a hypermetabolic state.

5. Systemic Response to Burns
• Loss of fluid into extravascular compartment
resulting in hypovolemia and shock
• Hyperventilation with increased oxygen demand
• Inhalational injury causing decreased oxygenation
and ARDS
• Initial decrease followed in several days by a
significant increase in in blood viscosity
• Gastric dilation and ileus occurs in the first 3 days
postburn.
Multi-organ system failure

6. CLASSIFICATION OF BURNS
On the basis of Causative Agent
1. Thermal
• Heat: creates a zone of coagulation, where tissue
is destroyed, and a zone of stasis, an area of
decreased blood flow. This area may improve or
get worse depending upon treatment.
• Cold: damage occurs as a combination of actual
freezing plus decreased blood flow and ischemia.
Commonly, alcohol is involved in these injuries.

7. CLASSIFICATION OF BURNS
2. Electrical
• Superficial damage may appear minimal. However,
the deeper tissues (muscle and bone) may have
severe injuries. The electrical current travels through
the body following the path of least resistance.
• This turns out to be the nerves, arteries, veins, and
bones. The current causes damage all along the
course through the body. Because of its smaller
cross-section area, there is a relatively greater
resistance at the exit site, causing a greater build up
of heat.

8. CLASSIFICATION OF BURNS
This often leads to an explosive release of built
up energy and significantly more extensive
damage at the exit wound than entrance.
Injury observed in conjunction with electrical
burns includes:
•Radiculopathy from hyperextension caused by
tonic/clonic contractions during electrocution.
• Peripheral neuropathy caused by direct injury
from the current.
.

9. CLASSIFICATION OF BURNS
• Cognitive impairment
• Spinal cord injury
• Formation of heterotopic bone around joints
and in residual limbs
• Cardiopulmonary arrest.
• Will be at risk of developing early onset of
cataracts and hearing loss, both amenable to
usual treatments.

10. CLASSIFICATION OF BURNS
3. Chemical
From either acid or alkali exposure. These
burns are typically underestimated and will
frequently appear to be mild in severity.
However, inappropriate or insufficient removal
of the causative agent allows the injury to
progress.
.

11. CLASSIFICATION OF BURNS
4. Radiation
Risk and severity of burn will depend upon
duration and intensity of exposure. Response
will vary from mild erythema to blistering and
skin sloughing over a period of hours to days.
If exposure is high enough, treatment can only
be palliative.

12. FACTORS AFFECTING OUTCOME
1. Age—infants, children, and the elderly have a
poorer rate of survival.
2. Total body surface area (BSA)—the greater the
area of involvement, the worse the prognosis.
3. Depth of burn—as the total BSA that is full
thickness increases the prognosis decreases.
4. Other associated injuries—prognosis decreases
as the number of concurrent injuries

13. Burn Severity Classifications

14. Diagram of normal skin histology with depth of burn injury indicated. Note the
layers, epidermis and dermis, and skin appendages.

15. Scald injury. Note the splash marks
and irregular depth of burns.

16. The rule of nines is used to estimate the percent of
body surface area burned

17. American Burn Association Criteria
for Referral to a Burn Center
• Partial-thickness burn greater than 10% TBSA
• Burns that involve the face, hands, feet, genitalia,
perineum, or major joints
• Any full-thickness burn
• Electrical burns, including lightning
injury,Chemical burns,Inhalation injury
• Burn injury in patients with preexisting medical
disorders that could complicate management,
prolong recovery, or affect mortality

18. American Burn Association Criteria
for Referral to a Burn Center
• Any patient with burn injury and concomitant
trauma in which the burn injury poses the
greatest risk of morbidity and mortality
• Burned children in hospital without qualified
personnel or equipment for the care of
children
• Burn injury in patients who will require special
social, emotional or rehabilitative intervention

19. Skin Regeneration and Scarring
• Spontaneous re epithelialization is impossible
with a full thickness burn injury because of
destruction of the dermal appendages.
• Full-thickness burns result in hair loss, sensory
impairment, loss of normal skin lubrication,
and heat intolerance because of destruction
of sweat glands.

20. Skin Regeneration and Scarring
• Healing and regeneration of skin in partial-
thickness burns arise from the epithelial
linings of the hair follicles and sweat glands
(stratum basale).
• Depending on the depth, healing is completed
within 14 to 21 days.

21. Skin Regeneration and Scarring
• The new skin again functions as a temperature
regulator and a protective barrier against
bacteria.
• After epithelialization there is continued
healing with regeneration of the peripheral
nerves, sometimes associated with symptoms
of neuropathic pain and itching.

22. Skin Regeneration and Scarring
• Although epithelium covers the wound,
dermal scarring occurs in the burn wound on a
continuous basis for several months after
injury.
• The healing process is ongoing from 6 months
to 2 years until the skin is mature. By that
point the vascularity of the wound has
returned to near normal, and there is no
further collagen deposition in the wound

23. Acute Care of Burn Wounds
Initial Treatment
• Always begin any emergency assessment with
an evaluation of the ABCs: Airway,
Breathing,Circulation.
• Special considerations include:Resuscitation
with fluids. Use Brooke, Evans, Baxter,
Parkland formula as a guide.

24. Acute Care of Burn Wounds
• Parkland formula: 4 cc/kg body weight
multiplied by % BSA burned = 1/2 of the total
calculated
fluid requirement should be given in the first 8
hours. The remaining amount divided equally
over the next 16 hours.
• Escharotomy: an incision of burned tissue to
relieve pressure from edema and avoid
neurovascular compromise and amputation

25. Acute Care of Burn Wounds
• Nasogastric tube (NGT) for abdominal
decompression and Foley catheter for
volume management
• Tetanus toxoid vaccination
• Cleaning all wounds with sterile saline
• Application of topical antimicrobials.
• Systemic antibiotics should await specific
indications and be culture driven.

26. Acute Care of Burn Wounds
• Rapid and extensive debridement and
grafting. The goal is to cover as much open
area as possible in as short a period of time as
possible.
• Nothing else will prevent complications,
decrease pain, and promote rapid recovery as
well as coverage of wounds.

27. Wound Healing
Phases
1. Inflammatory phase: response to injury with influx of
neutrophils and macrophages
2. Proliferative phase: new matrix is laid with fibroblasts
and in-growth of capillaries.
3. Maturation phase: resolution of inflammation in which
collagen is laid down to form the scar.
4. Epithelialization: reestablishment of the basement
membrane and epidermis
5. Wound contraction: the open margins are brought
together by fibroblasts.

28. Acute Care of Burn Wounds
The long-term goals of burn wound care are
to restore skin integrity, function, and
appearance, the immediate goals post
resuscitation are to prevent infection,
decrease pain, prepare wounds for grafting,
prevent contracture and scarring and maintain
strength and function.

29. Acute Care of Burn Wounds
• Debridement, the removal of eschar and
necrotic tissue, prepares a viable base for
wound healing and grafting.
• Eschar is a composite of coagulum and other
tissue debris like necrotic tissue, eschar
provides an excellent environment for
bacterial growth. Since eschar has no
microcirculation, bacterial invasion cannot be
resolved with systemic antibiotics.

30. Acute Care of Burn Wounds
• Debridement is performed by several methods. Water
immersion, water spray, and wet to dry dressing are
examples of mechanical debridement.
• Commercially available topical enzymes are available
for debridement and include substances such as
sutilains that induce proteolysis, fibrinolysis, and
collagenolysis.
• There are different types of surgical debridement.
Sequential, also called tangential, debridement is the
process of removing thin slices of necrotic tissue.

31. Acute Care of Burn Wounds
• Tissue is removed until a viable tissue bed is
reached. Fascial debridement surgically
removes tissue down to fascia.
• In this type, a viable wound bed is assured but
a significant soft-tissue defect results.
Circumferential fascial debridement places
patients at high risk for chronic edema.

32. Acute Care of Burn Wounds
• Deep skin burns are inelastic and the injured
skin does not accommodate to the massive
edema associated with acute burn injury.
• In a circumferential burn, the inelastic tissue
acts as a tourniquet. The tourniquet effect can
lead to a compartment syndrome, defined as
compartmental pressure of atleast 40 mm Hg.
If this occurs, escharotomy is indicated.

33. Escharotomy
• Escharotomy, surgical decompression of the
compartment, is urgently performed to avoid
necrosis of the underlying tissues that results
from sustained elevated pressure.
• Escharotomy incisions are performed along the
medial and lateral aspects of the extremity. This
procedure is critical in situations involving full-
thickness circumferential injuries of the chest,
arms, or legs.
• If escharotomy does not successfully reduce the
elevated pressure, a fasciotomy is indicated.

34. POSTACUTE PHASE
• Continue local wound care.
• Prevention of new injury from mechanical
irritants, the skin is now very sensitive.
• Lubricate skin several times a day.
• Oral antihistamines and pressure garments
(vascular support garments) for pruritus decrease
edema, lessen hypertrophic scars, and speed
wound healing. These garments should provide at
least 25 mm Hg or more and be worn 23–24
hours per day to reduce hypertrophic scarring .

35. POSTACUTE PHASE
• Provide protection from the sun as skin is
susceptible to repeat burns. Use long sleeves,
hats, and sunscreen.
• The skin will also be susceptible to topical
irritants, such as oil and gas, and these should be
avoided.
• Extremes of heat should be avoided in full
thickness burns as sweat glands are lost and the
ability to cool the body through sweating is lost.

36. Nutrition
• Adequate calories must be given to maintain a
positive nitrogen balance and promote muscle
and skin repair. Healing will not take place
without it, as the body is in a highly catabolic
state.
• This may require as much as 2000–2200
calories and 15 gm of nitrogen per square
meter of body surface area per day.

37. Nutrition
• Additional vitamin C, vitamin A, zinc, copper, and
manganese are important in wound care. The use
of additional supplementation is essential.
• Once the acute phase has passed, another
problem may appear. Burned fat cells are not
replaced.
• Overeating will cause weight gain in any area that
has not lost cells and can lead to disfigurement
secondary to relative obesity.

38. Grafting
• The introduction of early excision and grafting in the
last 40 years has contributed significantly to decreased
length of hospitalization as well as improved survival
rates, cosmesis, and functional outcome.
• Homografts, tissue taken from one’s own species,
include cadaveric tissue and human fetal membranes.
• Heterografts, also known as xenografts, are tissues
taken from nonhuman species that are used as human
grafts. These biological tissues, most commonly
porcine tissues, provide wound closure, modulate
metabolic needs, and reduce evaporative fluid.

39. Grafting
• These temporary grafts also act as a
mechanical barrier to infection and aid pain
relief. Temporary grafts are useful as “test
grafts” to determine if the wound bed will
accept an autograft. Typically, homografts and
heterografts are removed or replaced after
several days because the patient’s immune
system rejects them. It is not routine to use
immunosuppressant therapy in conjunction
with grafting.

40. Grafting
• Synthetic wound dressings are available, including
polyvinylchloride, polyurethanes, and other plastic
membranes.
• They are vapor and gas permeable. Such grafts are
employed until autografting is feasible or the wound heals.
Bilaminate analogs composed of thin sheets of silastic as
well as epidermal and dermal components are available.
Biobrane and Integra are the two most common
biosynthetic dressings.
• In the world of skin substitutes and biologic dressings,
autografts are the gold standard. The bioengineered
substitutes can be used as a temporary covering prior to
autografting, or as a neodermal base on which the
autograft is placed.

41. Grafting
• Autografts are harvested from the patient’s
own skin. In this process, skin is surgically
removed from one’s own body and is
relocated to another site.
• Autografts are placed on a wound bed clean
of any nonvital tissue or debris and without
evidence of infection.

42. Grafting
• Split thickness grafts are applied in sheets or may
be meshed prior to application. Cutting small
regularly staggered parallel slits in the sheet of
harvested skin creates a meshed skin graft. This
expands the size of the graft to several times its
original surface area.
• Meshed grafts are less cosmetic than full-
thickness grafts. Meshed grafts heal quickly, and
the epithelialization that occurs in the interstices
creates a meshlike appearance to the healed skin.

43. Grafting
• Full-thickness skin grafts are not meshed.They
are typically applied to cosmetically critical
areas such as the face, neck, and hands. In
addition, full-thickness grafts are used almost
exclusively in reconstructive surgery.

44. Harvesting donor site for autologous
skin graft.

45. Split-thickness skin grafts used to close wounds of residual limb after
amputation

46. Dysphagia
• Dysphagia is a common problem with large
burn injuries and complicates the delivery of
adequate nutrition for healing and recovery.
• Burn induced hypermetabolism increases the
caloric needs of the patient. Weakness,
inhalation injury, tracheostomy, medication,
oral motor dysfunction, and multiple other
factors contribute to the development of
dysphagia.

47. Dysphagia
• Tracheostomy is associated with aspiration,
pneumonia and the development of tracheal-
esophageal fistulae. Vocal cord paresis is
associated with inhalation injury and
endotracheal intubation.
• Vigilant monitoring is required to recognize
dysphagia early and prevent aspiration and
associated morbidity. demonstrated the
importance of evaluating patients.

48. Dysphagia
• Dysphagia was initially assessed by bedside
swallowing evaluation, and, if abnormal, followed
by modified barium swallow examination. They
found that oral phase dysphagia is usually due to
impaired range of motion (ROM), weak
mastication, and impaired oral seal from burn
wounds or scar formation.
• Esophageal dysfunction is a secondary
complication of intubation or tracheostomy., are
successful measures to reduce the risk of
aspiration.

49. Dysphagia
• Pharyngeal phase dysphagia is usually a result of
inhalation injury, complications of tracheostomy,
intubation, or burn scar. Pharyngeal dysphagia is
associated with the highest risk of aspiration.
• Interventions include evaluating endotracheal
tube position, size, and location. Selection of
appropriate food consistency and positioning,
including head and neck positioning, are
successful measures to reduce the risk of
aspiration.

50. REHABILITATION
• Restoration of independent function is the
ultimate goal of rehabilitation. Functional
restoration includes all aspects of the human life
such as strength, ROM, mobility and self-care,
reintegration into family and community,
adaptive psychosocial responses, and self-
determination.
• Rehabilitation after a severe burn injury is a
multistage process that may take years. Acute
rehabilitation goals include interventions to
facilitate wound healing, achieve pain.

51. REHABILITATION
• Skin grafts used to close wounds of residual limb after
amputation.
• Control, prevent joint contracture and weakness, and
promote independent mobility and activities of daily living
(ADL).
• Details of the injury, age, premorbid functional level, and
health are determinants of an individual’s rehabilitation plan.
• Therapy is individualized according to burn location, depth,
and size as well as other associated injuries or complications.
• Successful rehabilitation involves multiple disciplines working
collaboratively with the patient to achieve the highest level
offunctioning possible.

52. • Burn injuries pose complex physical and
psychological rehabilitation challenges.
• The incidence of burns has decreased
dramatically in the past 50 years as a result of
public education and home and work safety
efforts. Additionally, survival after burn injury
has increased significantly in the same time

53. • Advances in the field that have contributed to
survival include the formation of specialized
burn centers, early excision and grafting,
improved resuscitation and intensive care and
the development of topical and systemic
antibiotics. With dramatic improvements in
survival, the focus of burn care is increasingly
shifting toward rehabilitation.

54. • Burn survivors have complicated rehabilitation
needs including scarring, contractures, pain,
amputations, neurologic injuries, psychological
problems, and community integration issues.
• The period of rehabilitation may last from
months to many years after injury. The physiatrist
is an integral member of the burn care team from
the time of injury to long-term follow-up.

55. Positioning
• Contractures are a common complication of deep partial
and full-thickness burn injuries. Proper positioning is a
basic tenet of contracture prevention. Proper positioning
also helps prevent other complications such as pressure
ulcers and compression neuropathies .
• Contracture prevention is based on the principle of tissue
elongation. Patients often prefer to position injured tissue
in a shortened, nonstretched state for comfort. Typically,
this is a position of flexion and adduction. Such positions of
comfort lead to contracture. Positions of extension and
abduction are usually indicated to counter the position of
comfort.

56. Positioning
• One must prescribe positioning in accord with
the location of the injury and direction of the
contracture. Joints with overlying deep burns
are placed in a position of tissue elongation.
For example, a deep burn of the elbow is kept
in extension to avoid a flexion contracture that
would impede reaching

57. Positioning
• Contractures are not limited to joints. Other
areas, such as the soft tissue of the lips and
mouth, require stretching exercise, and
therapeutic devices to maintain tissue length
and function.

58. Therapeutic positioning to prevent contracture
formation.

59. Proper Positioning for Preservation of
Function in Acute Burns

60. Splinting
• Splints are commonly employed for burn injuries.
These devices provide multiple functions including
facilitating proper positioning, preventing joint
contractures, protecting skin grafts or fragile wounds,
or assisting desired motion.
• Splints are fabricated from many materials. Low
temperature thermoplastic orthotics are most
common. Low temperature plastics have several
advantages including the ability to be warmed at the
bedside in heated water and fitted to the patient
immediately. These plastics are conformable at low
temperatures and therefore can be readily remodeled
and adjusted as needed in the clinic or at bedside.

61. Splinting
• Custom splints can be designed for virtually all
parts of the body. Hand injuries commonly
require custom splints.
• Custom splints are advantageous for difficult to fit
areas and for sites that require unique design or
built-in features, such as facilitating motion at a
single joint. They are costly, require experienced
staff for construction and maintenance, and
necessitate that materials are available on site for
fabrication.

62. Splinting
• Commercially available prefabricated splints may be
cost effective; however, these splints often require
modification to fit properly or to achieve the intended
purpose. Some clinicians believe that the commercially
available prefabricated splints are best used for
positioning the knee and ankle.
• Splints that are simple and straightforward in design
and function are “user friendly.” Such splints are more
likely to be applied correctly and compliantly. An
incorrectly applied splint can lead to further injury,
including nerve damage, loss of skin graft, and other
skin trauma.

63. Splinting
• A properly designed and fitted splint avoids
pressure over bony prominences and is
compatible with wound dressings and topical
medications.
• It is often desirable to fabricate the splint
with moldable materials that can be modified
as a patient’s needs change.

64. Splinting
• The basic rule of splinting is to splint the body part in a
position opposite of the expected deformity. Factors to
consider when prescribing a splint include burn size,
burn location, burn type, functional goals, and patient
activity level.
• The wearing schedule for splints is individualized. In
the case of the comatose patient, splints should be
worn for 2 to 4 hours and then removed for a similar
length of time and then reapplied.
• The wearing schedule can be modified as the patient’s
level of participation is increased. Splints may be worn
to maintain the gains made in therapy.

65. Splinting
• If normal ROM of a joint is preserved, a splint is
not indicated unless a joint or tendon is exposed
or the patient is noncompliant with positioning.
Common splints include the knee extension splint
to prevent knee flexion contracture and posterior
foot drop splint to maintain neutral ankle
positioning.
• The upper extremity is the most common site for
contractures. For axillary burns, an “airplane”
splint is used to prevent shoulder adduction
contracture.

66. Splinting
• An “airplane” splint holds the upper extremity in
approximately 15 degrees of horizontal adduction
and 90 degrees of abduction. This splint prevents
shortening of the anterior and posterior axillary
folds.
• Modifications or inserts are used to maintain the
contours of the axillary apex and increase ROM as
tolerated. In injuries of other upper-extremity
joints, splints are fabricated to meet the specific
positioning demands of the elbow, forearm, and
wrist.

67. Splinting
To correct a contracture various static progressive
splints or orthoses are designed to provide a slow
progressive sustained stretch.
serial casting use in burn injury for
• Long duration of stretch with minimal force.
• Protection of exposed tendons
• Mechanical forces to remodel scar
• Cost-effective
•Treatment useful in children and noncompliant
patients

68. Splinting
•Treatment option when an open wound is
present. Splints are also valuable in the
postacute period to prevent contractures until
the tissue length is stabilized, after surgical
release of a contracture, or after skin grafting.

69. Hands
• Hands require special attention. When evaluating the
burned hand, individual joint motion should be assessed.
Limitations in ROM results from decreased tendon sliding,
decreased muscle strength, tendon shortening,
skin/muscle/ligament/ tendon tightness, joint restriction,
or a combination of these processes.
• During the acute phase, the hands are positioned and
splinted to prevent shortening of the joint capsules,
collateral ligaments, and muscle tendons. Edema can
complicate care as it accentuates metacarpophalangeal
(MCP) joint extension and interphalangeal (IP) joint flexion.
The resulting combination of MCP hyperextension and IP
joint flexion produces the intrinsic minus deformity of the
hand, also called claw Hand.

70. Hands
• The hand is splinted with the wrist in slight extension,
the MCP joints in 70 to 80 degrees flexion, IP joints in
extension, and the thumb abducted from the palm.
Fingers are positioned. If the burns are limited to the
palmar aspect, then the MCP and IP joints are
positioned in extension, fingers abducted, and the
thumb abducted from the palm.
• Palmar splints may need modifications to maintain the
palmar arch. Elastic wraps or straps are employed to
secure the splint. Elastic wraps are applied in a figure
of eight formation to avoid circumferential
constriction. Straps should be soft and applied in a
crisscross orientation.

71. Hands
• Circumferential hand burns often damage the web
spaces of the hand. Preservation of the web spaces is
important for hand rehabilitation. For example, loss or
shortening of the first web impairs thumb opposition
and abduction and interferes with grasp. Early
intervention is critical.
• In addition to abduction, exercise to all the digits, web
space dressings, and soft inserts or straps are placed in
the web spaces. Also, thermoplastic inserts may be
customized and fitted in these areas. Compression
gloves may be used in conjunction with the splints. In
mild cases, compression gloves may be sufficient to
preserve web spaces and function.

72. Hands
• Exposed tendons require splinting in a slack position.
The tendon should be kept moist to avoid desiccation
and denaturation. With time, the tendon may
revascularize and become functional.
• If the exposed extensor hood of the fingers is not kept
slack, the central slip can fail and lead to a boutonniere
deformity. In cases of extensor hood rupture, the finger
is positioned in extension. In approximately 6 weeks,
scar tissue may form to bridge the extensor surface
and act as a functional substitute

73. Hands
• After that time, active ROM can be initiated (18).
For exposed joints, a splint is prescribed to
provide protection. Gentle ROM is performed to
maintain motion. If the joint capsule is violated,
the joint is at risk for ankylosis. In such cases, the
joint is best placed in a function position.
• Edema can cause a claw hand. After 12 to 18
hours, edema changes consistency to a gelatinous
substance secondary to lymphatic vessel
occlusion and impaired fluid clearance.

74. Hands
• This gel like quality makes the edema more
difficult to resolve. In the acute stage after
injury, the upper extremity and hand are
typically suspended above the patient’s head
to aid fluid return and reduce edema.
• Care is taken not to stretch the brachial plexus
or damage the ulnar nerve. The resting hand
splint, with the inclusion of wrist extension,
contributes to edema control of the hand.

75. Hands
• This splint stretches the normally redundant
dorsal skin, thereby limiting space for edema
collection. Edema formation coupled with the
flexor tendon pull increases flexion at the IP joints
resulting in a claw hand deformity.
• Once skin closure is achieved, a compression
glove is prescribed to assist with edema control.
Passive exercise and scar suppression are also
employed to assure restoration and maintenance
of normal ROM.

76. Airplane splint fabricated to prevent
contracture
development of the shoulder.

77. Resting hand splint.

78. Compression gloves for hypertrophic
scar suppression

79. Exercise
• In burn rehabilitation, one of the earliest goals
of exercise is to maintain or achieve normal
ROM. For the obtunded or comatose patient,
passive ROM exercises emphasizing the end
ROM is appropriate. Alert and cooperative
patients can participate.

80. Exercise
• In active and active-assisted exercise. With
children, developmentally appropriate
exercise and play activities are indicated to
achieve the therapy goals.
• Surgical anesthesia can provide an
opportunity to perform ROM exercises and
determine objective measurements of range.

81. Exercise
• In this setting, one can perform ROM without concern
for pain. The opportunity to assess ROM under
anesthesia is valuable in the case of a child, an
uncooperative patient, or if pain is inhibiting ROM
exercise.
• Stretching exercises are prescribed when ROM is
abnormal.
• The biomechanics of skin and muscle are different;
therefore the two tissues are stretched differently.
Stretching of injured skin or scar tissue requires a slow
sustained mechanical stretch to enhance elongation of
collagen and underlying fibers.

82. Exercise
• When a prolonged stretch is performed, the stretch is
maintained until the tissue blanches. Blanching
indicates that the tissue is near its yield point, the point
at which the skin is at risk of tearing .
• After burn injury, muscular weakness, fatigue, and
deconditioning are serious problems. These sequelae
interfere with function, such as ambulation, ADL skills,
and endurance. Loss of muscle mass and, in children,
the additional loss of bone mass, interfere with the
restoration of function, return to work or school .

83. Exercise
• A structured exercise program composed of
aerobic and resistance training leads to increased
function as measured by increased muscle mass,
strength, and cardiovascular endurance.
• The efficacy of a supervised exercise program for
children, ages 7 to 18 years, that included
resistance and aerobic exercise. His team trained
children in eight basic exercises, including bench
press, leg press, and triceps curls under the
supervision of a physical therapist in an
outpatient setting.

84. Exercise
• Children had increased lean body mass and
muscle strength with structured exercise and the
concurrent administration of the anabolic steroid,
oxandrolone, for 1 year after injury.
• Anabolic agents, such as oxandrolone and human
growth hormone, have been demonstrated to
reduce the effects of hypermetabolism while also
increasing muscle mass and strength and
decreasing resting energy expenditure in children
and adults .

85. Exercise
• Individuals with small burns did not differ from
those without injury in muscle strength. However,
for those with greater than 30% TBSA burn
produced less torque, work, and power in their
quadriceps when compared to matched controls.
• A structured aerobic exercise program, consisting
of three times a week aerobic treadmill training
for 12 weeks combined with a standard burn
therapy program, achieved improved aerobic
capacity

86. Exercise
• Regular exercise after burn injury, like in other
adults, results in improved flexibility,
endurance, balance, and strength.
• Such gains are important for returning to full
independence and function. Other likely
benefits are reduced anxiety and an improved
sense of well-being .

87. Gait
• Independent walking may be the single most important
factor in determining discharge disposition after severe
burn injury.
• As soon as the patient’s condition permits, ambulation
should begin. In addition to reducing the risk for
contractures, deconditioning and deep venous
thromboses, early gait training maintains balance,
lower extremity ROM, strength, and endurance.
Physical therapists use a tilt table to perform graduated
upright positioning. Muscles of the lower extremities,
particularly the gastrocsoleus and quadriceps, are the
first muscles to lose strength with bed rest.

88. Gait
• Many consider new autografts to the lower
extremities a contraindication to ambulation.
Typically, ambulation is not initiated until the
surgeon is confident that the graft will tolerate a
dependent position.
• At 5 to 7 days after grafting, patients are
instructed to begin lower extremity–dependent
positioning. Dangling the lower extremities is a
preambulation exercise that helps determine if
the graft tolerates the dependent position.

89. Gait
• The application of elastic wraps or other elastic devices
are used to minimize venous pooling and decrease the
risk of graft loss. The typical protocol for dangling
begins for 5 minutes two to three times per day. If
inspection of the graft after dangling shows no signs of
intolerance, the duration is progressively increased.
• Once the graft shows tolerance for dependency,
ambulation is initiated. Supportive dressings such as
ace wraps are often employed. Like dangling, the time
spent walking is methodically increased as the graft
tolerates.

90. Gait
• Gait deviations are common after burn injury.
Some are transient while others persist. Early
correction of abnormal stance and gait
reduces the risk that the deviation will be
long-standing.
• Deviations result from pain, location of injury,
deconditioning, weakness, contractures, and
sensory and central nervous system
dysfunction..

91. Gait
• Gait devices are commonly used to protect
injured areas, reduce pain, or assist with weight
bearing. Devices are also employed to correct or
prevent poor posture or gait deviations
secondary to injury to the trunk or other areas.
• During times that the patient is unable to
ambulate, wheelchairs provide mobility and are
easily adapted to the patient’s specific needs.
Adaptations include attaching splints or wedges
to elevate the arm or adding lower-extremity
positioning devices.

92. SURGICAL RECONSTRUCTION
• The surgical goal is to minimize surgery and
maximize results.
• If multiple areas are involved, an overall plan and
timetable are developed that prioritize the fewest
number of surgeries with the maximal functional
benefit to the patient.
• The timing of surgical release of a contracture
varies. Some surgeons believe that surgery
should wait 6 to 12 months after injury. However,
there is limited evidence to support this
recommendation.

93. SURGICAL RECONSTRUCTION
• .There is evidence that early release does not worsen
outcome, and surgery is indicated with the
development of secondary deformities Tendon and
ligament injury impacts the completeness of the
release that can be performed. Age, severity of the
deformity, and time since injury impact surgical
outcome .
• Many reconstructive procedures are utilized in the
burninjured patient. Listed in the order of complexity
are Z-plasty, skin graft, local skin flaps, local muscle
flaps, fasciocutaneous flaps, free flaps, and cross limb
flaps .

94. SURGICAL RECONSTRUCTION
• Simple excision is indicated for scars that are limited in
size and location. Z-plasties are employed to limit or
correct joint contractures caused by hypertrophic
scarring. Contractures of soft tissue that disrupts
appearance or tissue flexibility are also treated with Z-
plasty. For example, this technique is employed to
correct hypertrophic scarring over the chin that
prevents adequate mouth closure.
• Release and skin grafting typically involves a fish-
mouth incision and graft placement.
• Scar pressure therapy and silicone application are often
combined with surgery to maximize outcome.

95. SURGICAL RECONSTRUCTION
• Severe axillary contractures are difficult to
treat . For tight bands formed near unburned
skin, five flap releases are used .
• Local flaps are often used if anterior or
posterior axillary fold contractures are
present.
• Contractures that are broader and involve the
entire axilla require fasciocutaneous or similar
flap procedures .

96. SURGICAL RECONSTRUCTION
• Contractures at the elbow are often complicated by
heterotopic ossification (HO) and this is taken into
consideration during the surgical plan .
• A Z-plasty or five flap release is used to treat a thin
band of scarring.
• Surgical intervention for hand contractures requires
expertise and experience.
• Full-thickness grafts are commonly used. Correction of
flexion contracture of the MCP joint has a higher
success rate than an extension deformity. K wires are
placed for 2 to 4 weeks after surgery for joint
stabilization.

97. SURGICAL RECONSTRUCTION
• Extension contractures of thumb exhibit poor
outcomes . Contractures associated with dislocated or
subluxed joints have the worst results .
• In recent years, face transplantation has garnered
significant interest in the lay press. The first reported
human face transplantation was performed in.
• These investigators utilize a cadaveric facial allograft
that requires lifelong immunosuppressive treatment.
There are unresolved questions regarding ethical,
immunological, and psychological issues about
immunosuppresants life long use.

98. COMPLICATIONS
Localized Neuropathies
• Peripheral mononeuropathies and plexopathies
are common in severely burned patients.
However, this complication is underreported in
the literature, as the diagnosis is often delayed or
missed entirely. The neurologic assessment is
complicated by the complexity of medical
problems and impaired consciousness of the
critically ill patient.

99. COMPLICATIONS
• It is also felt that elderly and diabetic patients are
predisposed to peripheral nerve compromise.
• Compression and stretch of peripheral nerves
places them at risk for injury. Bulky dressings can
cause compression to superficial peripheral
nerves.
• Improper and prolonged positioning is also a risk
factor.
• Clinical pearls of specific mononeuropathies and
brachial plexopathy are reviewed as next ppt
table

100. Localized Neuropathies
and Associated Risk Factors

101. BONE AND JOINT CHANGES
Contractures
• Contractures are defined as an inability to
perform full ROM of a joint. They result from a
combination of possible factors— limb
positioning, duration of immobilization and
muscle, soft tissue, and bony pathology.
Individuals with burn injuries are at risk for
developing contractures. Burn patients are often
immobilized, both globally, as a result of critical
illness in the severely burned, and focally, as a
result of the burn itself due to pain, splinting, and
positioning.

102. BONE AND JOINT CHANGES
Contractures
• Approximately 40% of hospitalized burn patients develop
contractures. The shoulder, elbow, and hand are the most
commonly involved joints (Fig. 43-13). Those with more
extensive burns, amputations, and inhalation injuries are
more likely to develop severe contractures (77). Positioning
and ROM exercises are the mainstays of contracture
prevention (18,78). Positions of comfort often include joint
flexion and adduction and lead to contracture formation.
For the bedbound burn patient, the ideal position to
prevent contractures involves neck extension, shoulder
abduction and external rotation, elbow extension and
supination, hip abduction, and ankle dorsiflexion (see Fig.
43-8). Such positioning is coupled with regular ROM
exercises

103. BONE AND JOINT CHANGES
Contractures
• Once a patient has developed a contracture,
treatment usually begins with conservative
measures, including splinting and serial
casting.
• Surgical correction of contractures is reserved
for contractures that significantly impact one’s
function and are not improved by
conservative measures.

104. Bone and Joint Changes
Bone and Joint Changes
Decreased growth in children with burns near the epiphyseal plate.
Bone growth deformity after burn injury. Also must change the size
of the compression garments frequently as children grow to
prevent deformity. Particularly true with pressure to the mandible
causing overbite.
Osteophytosis
• Found at the elbow and olecranon or coracoid process after burn
injury.
Heterotopic Ossifi cation (HO)
• Ectopic bone deposition in peri-articular soft tissue. Most common
site of HO joint involvement in burns is the elbow. Reported in up
to 23% of burn patients. Recommend pain free active ROM.

105. Bone and Joint Changes
Scoliosis and Kyphosis
• Can be seen with burns of the chest or back.
• May occur from protective posturing.
Joint Subluxations and Dislocations
• Seen with burns of the dorsal surfaces of the hands and
feet. During the healing process. skin pulls the joint
into hyperextension. If this continues chronically, it can
cause joint subluxation. Seen in MCP and MTP joints.
• Splint MCP in joint in flexion between 60 and 90
degrees, and exercise. Use a surgical high-top shoe
with a metatarsal bar 24 hours per day to prevent MTP
subluxation.

106. Burn contracture of the elbow.

107. SKIN COMPLICATIONS
Hypertrophic Scarring
• Hypertrophic scarring can result from deep partial- and
fullthickness burns. The scarring first presents as a firm, red
area of healed burn scar. It progresses over weeks to
become raised, erythematous and rigid .
• Scars can contract and if present over a joint, can
contribute to contracture formation. Over time scars
mature, taking on a pale, more pliable and less thick
appearance. This process may take up to 2 years. Scarring
can result in significant impairments in function. In addition
to physical impairments, hypertrophic scarring may lead to
psychosocial consequences. Scarring can impact
selfesteem, social isolation, body image, and community
reintegration .

108. SKIN COMPLICATIONS
Hypertrophic Scarring
• It is one of the most significant long-term
complications of burn injury. Histologically, scars
demonstrate a whorled collage pattern, in contrast to
the parallel array of collagen fibers in normal skin.
• Scar tissue exhibits a proliferation of fibroblasts and
capillaries, thickened epidermis, and a lack of rete
pegs. Endothelial cell proliferation results in occlusion
of the microvasculature leading to a local hypoxia.
With maturation, the microvasculature degenerates
and capillaries are reabsorbed.

109. SKIN COMPLICATIONS
Hypertrophic Scarring
• There exists a broad range of clinical presentations of
scars that include varied thickness, color, rigidity, and
corresponding symptoms.
• The prevalence of hypertrophic scarring is estimated
at greater than 60% of white and greater than 75% of
nonwhite survivors with severe burns. Interestingly,
scarring is not documented in neonatal, elderly, and
morbidly obese burn survivors. Prevalence data is
confounded by lack of a standardized objective
measure of hypertrophic scarring.

110. SKIN COMPLICATIONS
Hypertrophic Scarring
• The Vancouver Scar Scale is the most common
method of measurement; however, it is
comprised of subjective ratings of pigmentation,
vascularity, and pliability and as a result has a
relatively low interrater reliability.
• Risk factors for the development of hypertrophic
scarring include open wounds for greater than 2
to 3 weeks, burns that require grafting, and
heavily pigmented individuals. The etiology of
hypertrophic scarring is largely unknown.

111. SKIN COMPLICATIONS
Hypertrophic Scarring
• Pressure therapy. constitutes the main treatment
intervention. It is postulate that pressure (at least 25 mm
Hg) inhibits capillary blood flow resulting in local ischemia.
A decrement in tissue metabolism leads to impaired
fibroblastic activity and enhanced collagenase activity.
• Apoptosis ensues with release of proteases and liposomal
contents .The goal of therapy is to arrest scar development
and flatten existing scars. Initially, pressure wrappings are
applied around the affected areas using plastic elastic ,
cotton elastic or adhesive elastic bandages. As edema
resolves the scarred area assumes a more stable shape and
custom-made pressure garments are fit.

112. SKIN COMPLICATIONS
Hypertrophic Scarring
• It is recommended to wear compression garments 23
hours of the day until the scar matures, which can be
up to 2 years .
• Compliance with this regimen is difficult. The garments
are warm, socially awkward, and difficult to don. They
stretch and shift with wear, and replacement garments
are recommended every 3 months. Concave areas are
poorly compressed. To improve fit or pressure over
areas with challenging contour features, such as the
digital web space, silicone sheets or gels, sponges, or
conformed pieces of plastic are used to improve the
delivery of pressure and limit shear over the new and
fragile epithelium.

113. Hypertrophic scarring of the hand.
Note the raised and rigid appearance
of the scar.

114. Compression Garments:
Considerations in Children and Elders

115. Blisters
• Blisters are a common complication of partial-
thickness burns.Blisters result from
inflammatory changes after injury that
increases capillary permeability, thereby
permitting fluid accumulation between the
epidermis and dermis. Management of
blisters is a controversial topic in burn care.

116. Blisters
• Clinical practice guidelines for management of blisters in
partial-thickness burns. Small blisters (<6 mm) may be left
intact, as they are unlikely to rupture spontaneously,
damage underlying tissue, or impede healing. Large blisters
(>6 mm) should be debrided.
• Thick-walled blisters on palms and soles of feet need not be
debrided as they are less likely to become infected, and
debridement may cause patient discomfort and impaired
mobility.
• Debridement of blisters is associated with faster wound
healing and decreased scarring. Decreased scarring is also
associated with use of temporary skin substitutes to cover
the debrided site.

117. METABOLIC COMPLICATIONS
Catabolic State
• Patients with burns greater than 40% TBSA experience
a hypermetabolic response for at least 1 year after
injury.
• Catabolism contributes significantly to morbidity and
mortality.
• The catabolic state in burn injury is associated with
impaired wound healing, increased infection risk, loss
of lean body mass, slowed rehabilitation, and delayed
community reintegration. Pharmacologic and
nonpharmacologic strategies are implemented to help
reverse the effects of catabolism.

118. METABOLIC COMPLICATIONS
Catabolic State
• Nonpharmacologic interventions include early
burn wound excision and closure, aggressive
treatment of sepsis, maintenance of thermal
neutrality by elevation of the ambient
temperature, high carbohydrate, high protein
diet, and early institution of resistive exercises.
Pharmacologic interventions may include use of
recombinant human growth hormone,
• low-dose insulin infusion, synthetic testosterone
analog (oxandrolone) and b-blockade.

119. PSYCHOSOCIAL ISSUES
• Common psychosocial issues after burn injury
include posttraumatic stress, depression,
anxiety, sleep disorders, and community
integration.
• The research community has excelled in
identifying and describing these important
psychosocial issues after burn injury; however,
at the time of this publication few studies
have examined treatment interventions.

120. FACIAL BURNS
• Skin contractures and scars of the face are
challenging to prevent. Facial tissue is highly
mobile and has few points offixation. Common
facial deformities include ectropion of the lower
eyelid and microstomia of the mouth.
• The development of ectropion prevents eyelid
closing leading to eye irritation that may result in
corneal ulcers. Microstomia is a contracture of
the mouth that impairs mouth function.

121. FACIAL BURNS
• Current review of the literature indicates that
rehabilitation interventions for face burns lack
general agreement. No generally accepted
medical or rehabilitation protocols exist.
• However, a recent survey indicates that the
common treatment methodologies include
positioning, splinting, exercise, stretching, and
pressure therapy .

122. FACIAL BURNS
• During the acute phase many begin treatment with
splintsfor the neck, mouth, nose, and ears. Active ROM
of the face, including eyes and mouth, is initiated as
soon as the patient can participate. For ear injuries,
pillows are used to prevent chondritis and tissue
adhering to the bed linens. Devices are fabricated to
relieve pressure for an injured pinna.
• Microstomia is a contracture of the oral aperture of
the. It is associated with impaired oral hygiene, eating,
and speech. In addition, microstomia may disrupt
muscular and dental development in children

123. FACIAL BURNS
• The contracture may involve the skin of the
mouth or involve the perioral musculature
that creates the sphincter of the mouth.
• The orbicularis oris muscle is separated from
the surface by a thin subcutaneous layer and
from the mucosa below by a thin submucosal
layer.

124. FACIAL BURNS
• Oral stretching splints are used to maintain the
normal dimension of the mouth for those at risk
of developing microstomia.
• These splints are often custom made and tailored
to maximize comfort and benefit. Commercial
devices are also available. Splint designs vary by
direction of force (horizontal, vertical, or
circumoral stretch) and orientation (intraoral or
extraoral). Monitoring is required for skin
irritation and breakdown.

125. • Factors to consider in prescribing a
microstomia splint include age, dentition,
stage of dental development in children, and
location and depth of injury.
• Devices should be comfortable to wear, insert,
and clean. Compliance is often challenging. To
maximize success and achieve optimal patient
compliance, a graduated wearing schedule is
advised and more than one device is indicated

126. Microstomia from facial burns.

127. Transparent face mask with magnets
to secure eye
glasses

128. SUMMARY
• With more patients surviving burn injuries, care is increasingly
focused on the complications, rehabilitation, and long term
outcomes of burn survivors. Burn injuries may present as major
catastrophic injuries, with a complex array of problems that include
contractures, hypertrophic scarring, pain, neuropathy, and
psychosocial problems. Physiatry is an integral component of the
specialized multidisciplinary burn care team throughout the
continuum of care.
• Rehabilitation interventions begin immediately after injury in the
intensive care unit aimed at preventing long-term complications
of burns.
• Splinting, positioning, and exercise are hallmarks of early
rehabilitation. Burn care may continue for years after hospital
discharge, managing physical and psychosocial impairments after
burn injury and ultimately promoting maximal reintegration into
the community.

129. References by
DeLisa's Physical Medicine and
Rehabilitation:Principles and Practice
Krusen's Handbook of Physical Medicine and
Rehabilitation

130. THANKING
YOU