BURN

RELATED ANATOMY:

Skin is the largest organ of the body, comprising ~ 15% of total body weight.

Anatomically it has two distinct layers of tissue:

• A. Epidermis
o outermost layer exposed to the environment
o composed of multiple layers, is avascular and performs several vital functions
▪ a.1. Stratum corneum – gives the skin its waterproof characteristics and serves
the role of protection from infection.
▪ a.2. Stratum granulosum – layer responsible for water retention.
▪ a.3. Stratum spinosum – adds a layer of protection
▪ a.4. Stratum basale – contains cell that enable the epidermis to regenerate, as
well as melanocytes, the cells that determine skin pigmentation.
• b. Dermis
o the deeper layer, subdivided into papillary and reticular dermis
• The third layer, although not part of the skin per se is involved in the anatomical consideration
of the skin – the subcutaneous fat cell layer. Located directly under the dermis and above
muscle fascial layers
• Sensory Receptors

Epidemiology:

• It is estimated that 1.25 million people experience burn injuries each year.
• ~ 500,000 receive some form of medical treatment and 40,000 are hospitalized.
• Men between ages 16 and 40 have the highest incidence of injury. ]=
• 2/3 of burn injuries affect adults and 1/3 affect children.
• Most burns occur by fire/flame (43%) or scald injuries (36%).
• ~ 1/3 of burn injuries are associated with concomitant alcohol or drug use.
• Most injuries (65%) are result of an accident that is not work-related.
• A minority of burn injuries (17%) occur at work.
• ~ 5% of burn injuries are the result of child abuse or adult assault or abuse.
• Among children less than 2 years old, burn injuries represent the most common cause of
accidental death; most of these deaths are a result of abuse.
 • Overall, the survival rate is approximately 95%. The risk of death is increased for those at the
extremes of age, with inhalation injury and with larger burns.

Etiology:

• The most common cause of burn injury in children 1 to 5 years of age is from scalds from hot
liquids.
• The primary cause of burn injury in adolescents and adults is accidents with hot liquids.
• Fires that occur in homes and other structural dwellings are the leading cause of burn injury in
other age groups.
• Most deaths associated with home or structure fires are due to inhalation injury.
• Other etiologies that comprise the minority of burns include electrical, contact, chemical, tar,
radiation, and grease injuries as well as skin diseases.

Pathophysiology:

A burn wound typically consists of three zones.

a. Zone of Coagulation
• cells are irreversibly damaged and skin death occurs
• equivalent to a full-thickness burn and will require a skin graft to heal
• because of the lack of viable tissue and the amount of eschar, the risk of infection is
increased
• need for careful monitoring, the use of antibiotics, and the treatment of a burned
patient in a specialized burn center
b. Zone of Stasis
• may die within 24-48 hours without specialized care
• it is in the zone of stasis that infection, drying, and/or inadequate perfusion of the
wound will result in conversion of potentially salvageable tissue to completely
necrotic tissue and enlargement of the zone of coagulation
• splints or compression bandages, if applied too tightly, can compromise this area
c. Zone of Hyperemia
• site of minimal cell damage
• the tissue should recover within several days with no lasting effects

The two layers of the skin

• the epidermis and dermis differ morphologically and may heal by separate mechanism:
o a. Epidermal Healing
o b. Dermal Healing
▪ 1. Inflammatory phase
▪ 2. Proliferative phase
▪ 3. Maturation phase

Ancillary procedure:

• CBC
• MRI
Differential Diagnosis:

Take note!
S:>

Ocular Inspection:

• Bedrest
• A/C/C
• In apparent pain distress d/t severe burn injury in a specific area/ respiratory distress d/t
inhalation injury
• Possible deformities if a segment is not positioned properly
• Swelling on the wound area d/t burn injury
• (+) erythema on the area of the wound d/t inflammation
• (+) wounds d/t burn maybe dry, moist or purulent c or s discharge
• (+) gauze over the wound if underwent wound care
• Possible blisters if superficial thickness burn
• (+) hypertrophic scarring
• Possible scaly or dark skin
• Possible skin trophic changes
• Possible atrophy d/t prolonged immobilization
• Possible Contractures d/t position of comfort
• Possible postural deviation d/t prolonged immobilization

Palpation:

• Hyperthermia on wound area d/t inflamation

• Normotonic since UMN is not involved
• Tenderness localized on the affected area
o Grade 4 tenderness: pt doesn’t want to the area to be touched
o Grade 3 tenderness: (+) jumping sign
o Grade 2 tenderness: pain upon palpation c evident facial grimacing
o Grade 1 tenderness: pain upon palpation s facial grimacing
• Skin blanches if 2° degree burn
• Skin does not blanch if 3° degree burn
• (+) Muscle spasms
• (+) Muscle guarding d/t pain upon movement
• (+) Edema on the distal extremities

ROM:

• PT uses a goniometer to measure the ROM of an affected joint

o Proximal arm
o Distal arm
o End feel
• LOM on affected joints d/t pain, swelling, contractures and deformities p prolonged
immobilization
• Abnormal End feels common: Boggy and Empty
MMT:

• Break test- when resistance is applied to the body part at the end of the available range of
motion.
• PT places the pt in an appropriate and comfortable position
o Grade 5- Normal- Full ROM, against gravity c maximal resistance applied by PT
o Grade 4- Good Full ROM, against gravity c moderate resistance applied by PT
o Grade 3- Fair- Full ROM, against gravity s resistance
o Grade 2- poor- Full ROM, gravity eliminated position s resistance
o Grade 1- Trace- No ROM, there is palpable contraction
• Initially grade 3 testing is performed, if pt can’t achieve grade 3 muscle strength. PT will place the
joint in a gravity eliminated position to test for grade 2 muscle strength, then if pt can do it without
difficulty, PT applies moderate resistance for Grade 4 and maximal resistance for grade 5.
• Significant muscle weakness on affected joints depending on the progression of the disease. This
is d/t prolonged stretching caused by contractures and deformities

Neuro Evaluation:

• PT uses a neuro hammer to test for deep tendon reflexes

• If burn injury is severe that it has affected nerves, pt may become hyporeflexive
• PT uses brush for light touch, pin for pain, and PT thumb for pressure
• Pt may have impaired superficial and deep sensation if burn injury is severe

Gait Analysis:

Specific abnormal gait but phases of gait may be affected depending on the areas affected by burn injury

• cadence: ↓
• BOS: ↓
• Step length and stride length: ↓
• If UE is affected: (-) or ↓ arm swing

Postural Analysis:

• Pt is assessed in standing position through anterior, posterior and lateral view

• There is possible postural deviations if there is significant muscle tightness, spasms and
deformities which is a common clinical manifestation of pts c RA

Special Test:

Tests for tightness

Anthropometric measurement

• MBM
o PT uses a tape measure to compare the muscle bulk of 2 extremities to check if there is
significant atrophy; usually 3 land marks are used as reference for measuring; 2, 4, 6 in
above or below from the prominent landmark
• LGM
 o PT uses a tape measure to compare the size of 2 extremities caused by edema
• Figure of 8 measurement:
o Used for assessment of swelling in distal extremities
o PT uses a tape measure to test B extremities and average of 3 trials is computed

Functional Assessment:

• Pt is dependent in all ADLS such as self-care bed mobility, ambulation and transfers in the acute
phase of injury since pt may be confined in bed if the burn is severe. If injury is not severe, pt may
be independent but presents difficulty in performing ADLs as the wound area may be painful if
segment is moved.

A:

Problem list:

Impairment based:

• Intense pain on the wound area c PS 8/10- 9/19 caused by burn injury
• Swelling on wound area
• LOM on burn area caused by contractures
• Edema on extremities
• Muscle weakness caused by immobilization
• Difficulty in performing ADLs such as self-care, bed mobility, ambulation, transfers and other
recreational activities
• Deformities formed by contractures
• Postural deviations

STG:

• ↓ Intense pain using PS as reference of improvement eg: 7/10 → 4/10

• Improve difficulties in performing ADLs using appropriate functional outcome measures from
maximum → mod → min
• ↓ joint swelling using tape measure for assessment
• ↑ ROM of affected joints c increments of improvement eg: 5° increments or 10 ° increments
• ↓ edema on extremities using LGM assessment
• ↑ muscle strength of affected muscle c muscle grading as reference of improvement eg: from
grade 3 → 4 → 5
• Improve postural deviations using tactile and verbal cues

LTG:

• Pt will be able to report no pain upon movement c no joint swelling and edema, ↑ ROM and
muscle strength, demonstrate proper posture in performing ADLs and recreational activities using
testing criteria of PS, ROM and MMT assessment, gait and postural analysis and functional
outcome measures.

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Hydromodalities

• Pulsed US on affected forearm and wrist x 1.5w/cm2 x 1 MHz x 5’ to ↓ swelling and ↑ tissue
extensibility.

• FUP x 10’ to ↓ edema

Electromodalities:

• TENS on affected areas x 20’ to ↓ pain

• ES on areas c muscle atrophy x 10’ to retard muscle atrophy

Tx:

1. PROM on affected joints c burn injury x 10 reps x 1 set to prevent joint stiffness and contractures
2. Cross fiber massage on a scars caused by burn injury x 5’ to to prevent formation adhesion and
scar tissue
3. Isometric exercises on areas affected by burn x 8sh x 10 reps x 1 set to prevent muscle atrophy
4. GPS on affected areas or areas susceptible to contractures such as shoulder, elbow, hip and knees
to ↑ ROM and prevent contractures
5. Flexor tendon gliding exercises x 10 reps x 1 set to preserve ROM of hand, if hands are affected
6. Marble picking exercises x 10 reps x 1 set to improve fine motor skills of the hands
7. PRES using DB or TB on weakened muscles x 10 reps x 1 set to ↑ muscle strength
8. Postural exercises x 10 reps x 1 set to improve posture
a. Shoulder shrugs
b. Scapular squeeze
c. Chin tuck exercises
d. Cat and camel exercise
9. Aerobic exercise such as stationary cycling x 10’ to ↑ cardiovascular endurance
10. Deep breathing exercises x 10 reps x 1 set to improve breathing and respiration
11. Gait training

Orthosis:

• Wheel chair- used by patients c severe contractures and deformities of LE such as hip and knee
• Bandages
• Hip abduction pillow
• Airplane splint
• Resting hand splint
• Finger extension splint
• Interdigital inserts

HEP:

• AROM
• Self Stretching
• Flexor Tendon gliding
• PREs using bottled waters
HI:

Instruct pt:

1. Observe proper body mechanics

2. Observe proper gait

3. Avoid painful stresses on affected hip

4. Monitor activities and stop when discomfort or fatigue begins to develop.

5. Use frequent but short episodes of exercise (three to five sessions per day) rather than one long
session.

6. Alternate activities to avoid fatigue.