Burns

BURNS
What are burns?
Injuries to tissues caused by:

Friction
Heat
Electricity
Radiation
Chemicals
Thermal burns
Flames
Hot liquids
Hot objects
Gases
Electrical burns
Accidental electrical
contact
Depend on:
 strength of electrical
current
 duration of contact
 Common causes : workplace
injuries
 Rare causes: lightning
Radiation burns
UV light
X-rays
Sunlamps
Radiation therapy
Chemical burns
strong acids
strong bases
detergents
solvents
First-degree burns/superficial burns
epidermis
symptoms
 redness
 pain
 dry skin
 no blisters
 no scars
example – mild sunburn

Epidermis will peel off in 2 to 3 days.
Second-degree burns
epidermis and part of

dermis
symptoms
 blisters
 deep redness
 wet and shiny
 very painful to touch
 no scars
example – contact with
hot objects or flame
Third-degree burns
epidermis and entire

dermis
symptoms
 dry and leathery skin
 swelling
 black, white, brown or
yellow skin
 lack of pain
example – electrical or
chemical sources, flames
Fourth-degree burns
epidermis, dermis and underlying tissue

Full thickness that extends into muscle and bone.
symptoms
 black skin
 no sensation
example - flames
Complications of burn injury
1) Infections
2) Pulmonary complications
-inhalation injuries
-pneumonia
3) Metabolic complication
4) Cardiovascular complication
5) Heterotopic ossification
Neuropathy
Pathological scars.
Infection
Bacterial infections are cause of system failure.

Systemic effects
Once the burn covers more than 30% of TBSA, the injury has
a systemic effect due to
 Molecular structural alterations

 Release of toxic metabolites
 Release of antigen and immunomodulatory agents
Histamine, Serotonin, Bradykinin, Nitric oxide, etc.
 Causes systemic shock, cardiovascular, respiratory and
renal failure, immunosuppression and hypermetabolism.
Cardiovascular Changes
 Myocardial contractility decreased

 Oedema formation
 Capillary permeability is increased leads to loss of
intravascular proteins and fluids to the interstitial
compartment
 Hypovolemia
Secondary to oedema and rapid fluid loss from
surface of wound
Peripheral vasoconstriction occurs , May cause renal
failure
Respiratory Changes
Inflammatory mediators cause bronchoconstriction

and pulmonary oedema
severely burnt adults acute respiratory distress

syndrome (ARDS) can occur.
Exacerbated in the case of inhalation injury

Metabolic Changes
Hypermetabolism begins approximately five days

post burn
Metabolic state is initially suppressed by the effects
of acute shock , Can persist for up to two years post
injury .
Increased body temperature
 Increased oxygen and glucose consumption
 Increased CO2
Increased heart rate for up to 2 years post burn
Physiotherapy aims
1. Prevent respiratory complications

2. Control Oedema
3. Maintain Joint ROM
4. Maintain Strength
5. Prevent Excessive Scarring
Burn Site and Impact
the following require specialized treatment

o Hands
o Face
o Perineum
o Joints
Physiotherapy Assessment of the Burn Patient
The physiotherapist must be aware of the

importance of an early and adequate assessment of
Burn patients for optimal functional and cosmetic
outcomes to minimise the impact of the trauma long
term.
They must have a concise knowledge of the
assessment procedure through from Accident and
Emergency to the ward, onto the rehabilitation
setting and out in the community.
Subjective Assessment
Total Body Surface Area
(TBSA)
A burn of > 20 – 25% TBSA creates a global or
systemic inflammatory reaction affecting all body
organs and indicates a significant risk for the
respiratory system
History of Presenting Complaint
History of the incident with specific attention paid to the mechanism

of injury.
First aid – was adequate first aid given? - If not, suspect deeper burn
injury
Falls – was there any indication that the patient fell? From what
height? – possible head injury, sprains or fractures
 Electrical injury – voltage involved? Parts of body in contact with
earth? – suspect nerve and deep muscle injury with high voltage
current
Explosions – falls, high velocity injuries, possible tympanic
membrane injury – loss of hearing and difficulty communicating
Passage to hospital and time to admission
Medical and Surgical History
Any surgical or medical management

 Pain medication
 Debridement
 Escharectomy
 Flaps/grafts
Considerations for the Assessment of Hand Burns
The area of the hand that is injured has a huge

impact on recovery.
A burn on the hand can have detrimental effects for
ADLs and functioning.
Dependent on the area and depth of the burn, it may
lead to significant deformity
Assessment of hand
Evaluation and classification of the size and depth of the burn of

the hand
Post burn Hand Deformities
Web space contractures

 Dorsal skin contractures
Digital flexion contracture
Boutonniere deformity
Dorsal skin deficiency
Digital loss secondary to ischemia
Median and ulnar nerve compression
Conservative or operative
treatment
Surgical management—
removal of eschar,
transplantation of skin
grafts, flap
Early postoperative
physical therapy
Objective Assessment
Observational behavioral pain assessment scales

should be used to
Measure pain in children aged 0 to 4 years e.g. The
FLACC scale
 Faces pain rating scale can be used in children aged
5 years and older. E.g. The Wong-Baker FACES pain
rating scale
 VAS can be used in children aged 12 years and older
and adults.
Oedema Assessment
Mobility Assessment
The assessment and treatment of mobility can be

separated into two aspects –
the limbs & trunk, and
general functional mobility (e.g. transferring and
ambulation).
Limb and Trunk
Assessment of limbs and
trunk should include
joint ROM and strength.
Limiting factors may

include pain, muscle
length, scar contracture .
General Functional Mobility
All functional transfers, gait, endurance and balance

should be assessed once the patient is medically
stable.
Factors to consideration when assessing mobility:
 Posture
 ADLs
 Cardiovascular response to mobilisation
 Neurological status
 Pain
Paediatric Burn Pain
children 0-4 years represent approx. 20% all hospitalized

burn patients
In preschool aged children the half-life of opioids
(morphine ) are 50% those in adults. Higher dosage
required.
Risk of accidental overdose due to difficulties with pain
evaluation resulting in overestimation of child’s pain
Childs environment has huge effect on pain perception.
Parents’ presence and aid during dressing change can
have beneficial for procedural pain and reducing anxiety.
Role of the Physiotherapist in the Rehabilitation of the
Burn Patient
Treatment of patient with burn begins the moment the

patient arrives at the hospital, needs to modify daily.
Treatment is directed towards
prevention of scar contracture,
preservation of normal range of motion,
prevention of scar formation and deformity,
maintenance of muscle strength and cardiovascular
endurance,
return to preburn function and performance of
activities of daily life.
Control of edema and preserving range of motion
usually are the first priorities.
Elevation of extremities and active movements

especially of hands and ankles helps to minimize
edema formation.
Prevention of scar contractures can be accomplished

by positioning ,splinting and exercise.
immobilization
Positioning in the Acute Stage
Immobilization of the hand
The most common
deformity associated
with burns is the ‘claw’
deformity.
Splinting
Static Splinting dynamic splint
General indication for use of splints include:
Prevention of contractures.
Maintenance of range of motion achieved during
exercise sessions or surgical release.
Correction of contractures.
Protection of joint or tendon.
Splints are usually worn at night, when patient is
resting or for several days following skin grafting.
Splinting Precautions
Splints need to be cleaned regularly to prevent colonization by
microbes which may lead to wound infection
Unnecessary use of splinting may cause venous and lymphatic
stasis, which may result in an increase in oedema
 Precaution must be taken to ensure that splints do not product
friction causing unnecessary trauma to the soft tissues
Precaution must be taken to ensure that splints do not produce
excessive pressure. There is particular risk of pressure injury to
skin after burn injuries due to potential skin anesthesia
 Splinting should not be used in isolation but as an adjunct to a
treatment regime
Active and passive exercises
Active ROM
Depending on the need for immobilization gentle
active ROM exercises is the preferred treatment
during the acute stage of injury as it is the most
effective means of reducing oedema by means of
active muscle contraction.
If this is not possible due to sedation, surgical
intervention etc. then positioning the patient is the
next best alternative .
If the patient has just received a graft ,active and
passive exercises of the area should be discontinued
for 3 to 5 days.
Active assisted and passive exercises should be
initiated if the patient cannot fully achieve active
range of motion.
Frequency, Duration Recommendations
Physiotherapy intervention should be twice daily
with patients prescribed frequent active exercises in
between sessions.
For the sedated patient gentle passive range of
motion exercises should be done 3 times a day once
indicated .
Dependent on the severity of the burn active and
very gentle passive range of motion exercises for the
hand and fingers are begun from day one of injury.
Contraindications
Active or Passive range of motion exercises should
not be carried out if there is suspected damage to
extensor tendons (common occurrence with deep
dermal and full thickness burns).
Range of motion exercises are also contraindicated
post skin grafting as a period of 3-5 days
immobilisation is required to enable graft healing
Resistive and conditioning exercises
Exercises are progressed to strengthening exercises.

Exercises may include isokinetic,isotonic,and other
resistance training.
Therapist should monitor vital signs.
Patient should be encouraged to walk from burn unit
to physio. dept.
Cycling, rowing, treadmill walking, stair case
climbing and other forms of aerobic exercises should
be encouraged.
Scar management
Pressure garments.
Massage: deep friction,5 to 10 minutes,3 to 6 times

daily.
garments are worn for up to 23 hours a day, with
removal for cleaning of the wound and garment, and
moisturisation of the wound.
Duration: garments can be worn as soon as
wound closure has been obtained, and the scar is
stable enough to tolerate pressure. Post grafting, 10-
14 days wait is recommended.
Garments should be worn for up to one year.

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BURNS

What are burns?

Injuries to tissues caused by:

example – mild sunburn

epidermis and part of

epidermis and entire

epidermis, dermis and underlying tissue

Bacterial infections are cause of system failure.

 Molecular structural alterations

 Myocardial contractility decreased

Inflammatory mediators cause bronchoconstriction

severely burnt adults acute respiratory distress

Exacerbated in the case of inhalation injury

Hypermetabolism begins approximately five days

1. Prevent respiratory complications

the following require specialized treatment

The physiotherapist must be aware of the

History of the incident with specific attention paid to the mechanism

Any surgical or medical management

The area of the hand that is injured has a huge

Evaluation and classification of the size and depth of the burn of

Web space contractures

Observational behavioral pain assessment scales

The assessment and treatment of mobility can be

Limiting factors may

All functional transfers, gait, endurance and balance

children 0-4 years represent approx. 20% all hospitalized

Treatment of patient with burn begins the moment the

Elevation of extremities and active movements

Prevention of scar contractures can be accomplished

Exercises are progressed to strengthening exercises.

Massage: deep friction,5 to 10 minutes,3 to 6 times

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