BURNS
• It consists of 2 layers: SKIN
1. Epidermis : It is the
outermost &
superficial layer of
skin.
2. Dermis : Also
called as true
skin ,
20-30 times thicker
Epidermis
It consist of 5 layers :
a. Stratum germinativum
b. Stratum spinosum
c. Stratum granulosum
d. Stratum lucidum
e. Stratum corneum
Dermis
a. Superficial papillary layer
b. Deep reticular layer
Functions of the skin
1. Protection
2. Temperature regulation
3. Lubrication
4. Vitamin D synthesis
5. Sensations
Location of sensory receptors
STRUCTURE LOCATION FUNCTION
FREE NERVE ENDINGS EPIDERMIS PAIN , ITCH
FREE NERVE ENDINGS DERMIS PAIN
MERKEL’S DISKS STRATUM SPINOSUM TOUCH
MESSINER’S CORPUSCLES PAPILLARY DERMIS TOUCH
RUFFINI’S CORPUSCLE PAPILLARY DERMIS WARM
KRAUSE’S END BULB PAPILLARY DERMIS COLD
PACINIAN CORPUSCLE RETICULAR DERMIS PRESSURE , VIBRATION
Definition & causes
• A burn results in loss of skin with impairment
of skin functions .
CAUSES :
1. Flame
2. Chemicals
3. Hot fluids
4. Electrical
CLASSIFICATION OF BURN INJURY
• SUPERFICIAL BURN
• SUPERFICIAL PARTIAL THICKNESS BURN
• DEEP PARTIAL THICKNESS BURN
• FULL THICKNESS BURN
• SUBDERMAL BURN
Depth of Color/ Surface Swelling/
Appearance / Healing/
burn Vascularity Pain Scarring
Minimal edema;
Erythematous , No blisters , dry spontaneous
Superficial pink or red ; surface ; delayed healing ; minimal
irritated dermis pain , tender scarring
discoloration
Intact blisters,
moist surface ,
Bright pink or red; weeping or
Moderate edema
mottled red; glistening ; painful
spontaneous
Superficial partial inflamed dermis ; sensitive to
healing; minimal
thickness erythematous changes in
scarring;
with blanching or temperature ,
discoloration
capillary refill exposure to air
currents , light
touch
Depth of Color/ Surface Swelling/
Appearance / Healing/
burn Vascularity Pain Scarring
Broken blisters
Mixed red , waxy wet surface ;
Marked edema ;
Deep partial white ; blanching sensitive to
slow healing ;
thickness with slow pressure but not
excessive scarring
capillary refill to light touch &
soft pin prick
White, charred,
tan, black, red;
Parchment-like;
hemoglobin
leathery ,rigid, Area depressed;
fixation ; no
Full thickness dry ; anesthetic ; heals with skin
blanching ;
body hairs pull grafting ; scarring
thrombosed
out easily
vessels ; poor
distal circulation
Depth of Color/ Surface Swelling/
Appearance / Healing/
burn Vascularity Pain Scarring
Subcutaneous
tissue evident
Tissue defects ;
anesthetic;
Subdermal Charred heals with skin
muscle damage;
grafting ;scarring
neurological
involvement
Burn wound zones
It consists of 3 zones :
1. ZONE OF COAGULATION : Cells are irreversibly damaged & skin
death occurs .
2. ZONE OF STASIS : Injured cells may die within 24 – 48 hrs without
diligent treatment .
3. ZONE OF HYPEREMIA : Site of minimal damage , tissue recovers
with no lasting effects .
Rule of nine
COMPLICATIONS OF BURN INJURY
1. Infection
2. Pulmonary complications
3. Metabolic complications
4. Cardio-vascular complications
5. Heterotopic ossification
6. Neuropathy
7. Pathological scars
Infection
– Infection,in conjuncton with
organ system failure,is a
leading cause of mortality
from burns.
– Pseudomonas aeruginosa
and staphyloccoccus aureus
are resistent to antibiotics
and have been responsible
for epidemic infection in
burn centers.
Pulmonary complications
– Seen in the patients who burned in the closed
space – inhalation injury.
– Pneumonia Death
– Signs:
» Facial burn
» Harsh cough
» Hoarsness
» Abnormal breath sounds
» respiratory distress
» hypoxaemia
Metabolic complications
– The consequence of increased metabolic & catabolic
activity following a burn are rapid decrease in the
body weight, negative nitrogen balance, & a decrease
in energy stores that are vital to the healing process.
– Altered metabolism, protein from muscle tissue is
preferentially used as a source of energy. This
situation, coupled with the effects of the bed rest
causes muscles to atrophy and renders patients weak
from both their burn injury .
Cardio-vascular complications
– Haemodyamic changes result from a shift to the
interstitium
– Reduces plasma & intravascular fluid volume
– Tremendous initial decrease in C.O.
Pathological scar
Medical management of burns
INITIAL MANAGEMENT & WOUND CARE
1. Establish & maintain an airway.
2. Prevent cyanosis, shock & hemorrhage.
3. Establish base line data on the patient , such as extent
& depth of burn injury .
4. Prevent or reduce fluid losses.
5. Clean the patient & wounds.
6. Examine injuries.
7. Prevent pulmonary & cardiac complications.
Surgical management of wound
Primary excision :
• Surgical removal of eschar.
• Done within 1 week of injury.
• Approach is easier ,promotes rapid healing ,
reduces infection & scarring & is economic .
Physical therapy management
AIMS
1. Prevention of scar contracture
2. Preservation of normal ROM
3. Prevention or minimization of hypertrophic
scar formation & deformation
4. Maintenance & improvement in muscular
strength
5. Cardiovascular endurance
6. Return to preburn function
7. Performance of activities of daily living .
Anticipated goals & expected outcomes
1. Wound & soft tissue healing is enhanced
2. Risk of infection & complication reduced
3. Risk of secondary impairment reduced
4. Maximal ROM is achieved
5. Pre- injury level of cardio-vascular endurance
is restored
6. Good to normal strength is achieved
7. Independent ambulation is achieved
8. Independent function in BADL & IADL is increased
9. Scar formation is minimized
10. Patients, family & care-givers understanding of expectations
& goals & outcomes are increased
11. Aerobic capacity is increased
12. Self- management of symptoms is improved.
intervention
1. Positioning & splinting
2. Active & passive exercises
3. Resistive & conditioning exercise
4. Ambulation
5. Scar management
POSITIONING
JOINT COMMON MOTION TO BE SUGGESTED
DEFORMITY STRESSED APPROACHES
Use Double
Mattress; Position
Anterior neck Flexion Hyperextension Neck In Extension
(Rigid Cervical
Orthosiss)
JOINT COMMON MOTION TO BE SUGGESTED
DEFORMITY STRESSED APPROACHES
Shoulder Flexed &
Adduction & Abduction flexion
Shoulder& axilla Abducted
internal rotation & ext. rotation
(Airplane Splint)
JOINT COMMON MOTION TO BE SUGGESTED
DEFORMITY STRESSED APPROACHES
Flexion & Extension &
Elbow Splint in extension
pronation supination
JOINT COMMON MOTION TO BE SUGGESTED
DEFORMITY STRESSED APPROACHES
Wrist extn, MCP
Wrist extn ,MCP
Wrist flexion,Claw flex PIP & DIP ext
Wrist,Hand flex PIP & DIP ext
hand thumb abdn with
thumb abdn
large web space.
COMMON MOTIONS TO BE SUGGESTED
JOINT
DEFORMITY STRESSED APPROACHES
All motions esp. Hip neutral with
Hip & groin Flexion, adduction
hip ext & abd slight abduction
Posterior knee
Knee Flexion Extension
splint
Plastic ankle-foot
orthosis with
All motions esp.
Ankle Plantar flexion cutout at achilles
dorsiflexion
tendon & ankle in
neutral
Active & passive exercise
• Active exs begun on day of
admission.
• Just received skin graft exs
discontinued for 3-5 days – to
adhere skin graft.
• Active-assisstive & passive exs –
patient cannot achieve full active
ROM.
• Healed burned area lubricated
before exs are initiated.
Resistive & conditioning exs
• Progression – strengthening exs .
• Free weights & pulleys given.
• Monitoring of vital signs for the response to treatment.
• Cycling or rowing ergometry, treadmill walking, stair
climbing – to improve strength & ROM.
• Motivate the patient.
AMBULATION
• Initiated early
• Lower extremity skin grafted
– discontinue
• After skin graft it should be
wrapped in elastic bandage
figure of eight – to support &
promote venous return.
• Tilt-table treatment for
standing
• Assisstive device for
ambulation
Scar management
• During 3-6 months changes occur; healed areas
become raised & firm.
• Pressure – hasten scar maturation & minimize
hypertrophic scar formation by
1. Thinning the dermis
2. Altering biochemical structure of scar tissue
3. Decreasing blood flow to area
4. Reorganizing collagen bundles
5. Decreasing tissue water contentssss
Pressure dressing
• Elastic wraps – support donor
site , control edema & scarring
• Fig. of eight in lower limbs;
spiral in upper limb & circular
wrap on trunk.
• Worn for 23 hrs a day for 12-
18 mnths – assist scar
remodeling.
• Pressure result in flat, pliable
scars & relief of itching.
Necessary until scar
maturation, when scars are
pale, flat & soft.
massage
• Assist in ROM – making tissues more pliable.
• Deep friction massage – loosen scar by
mobilizing & break up adhesions.
• Immature scar elongate & contracture is
corrected – along with ROM
• Firm scars – tend to soften
• Done in slow, firm manner for 5-10 mins, 3-6
times daily.
Camouflage make-up
• Used in scars of face, neck
& hands .
• Useful when person has
hyperpigmentation or
hypopigmentation due to
burn .
• Cosmetics are opaque ,
color correct burn scars ,
available in multiple
shades .
Thank you
