Rehabilitation of the Patient with Burns

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Rehabilitation of the Patient with Burns

• U.S. Army Medical Specialists Corps
• Management of Burns and Multiple Trauma
• San Antonio, TX
• August 22, 2005
• Reg Richard, MS, PT

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• Burn Wound Assessment
• Classification

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Sources of Burn Injury

• Flame
• Hot liquids
• Hot gases
• Contact
• Chemicals
• Electricity
• Friction
• Radiation

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Additional Burn ExtentConsiderations

• Size of hand 1 TBSA
• Donor sites add to extent
• Amputations subtract from extent
• Total Body Surface Area

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Depth of Cellular Damage

• 1st degree Epidermal
• 2nd degree Partial-thickness
• 3rd degree Full-thickness
• 4th degree Subdermal

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Burn Center Referral Criteria

• Partial-thickness burns gt10 TBSA
• Full-thickness burn in any age group
• Burns that involve the face, hands, feet,
• genitalia, perineum, or major joints
• Patient with pre-existing medical disorder
• Inhalation injury

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Burn Referral CriteriaContinued

• Electrical burns, including lightening
• Chemical burns
• Patient with concomitant trauma
• Children
• Patients who require special social,
• emotional or long-term rehabilitation

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Epidermal Healing

• Migration
• Proliferation
• Differentiation

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• Dermal Healing
• Scar Formation

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Phases of Healing

• Inflammation
• Proliferation
• Maturation

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Inflammatory Phase

• Initial biologic response
• Minimize blood loss
• Eliminate offending agents

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Proliferation

• Epithelialization at surface of wound
• Formation of granulation tissue by capillary
  budding
• Collagen synthesis by migrating fibroblasts
• Contraction of wound by fibroblasts
• Tensile strength increases

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Granulation Tissue

• Capillary budding ?
• Neo-vasculature
• 1. Provides nutrients
• 2. Scaffold for cell migration
• Macrophages Fibroblasts

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Collagen Synthesis

• Amino acids bind polypeptide chain
• Hydroxlated polypeptide chain procollagen
• 3 protocollagen tropocollagen
• Tropocollagen units collagen filament
• Bundles of filaments fibril
• Collection of fibrils fiber

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Wound Contraction

• Active process to close wound

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Cells Responsible forWound Contraction

• Fibroblast
• Myofibroblast

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Wound Contraction

• Characterized by the centripedal movement of the
  whole thickness of surrounding skin

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Wound Contraction

• Edges meet
• Excess tension

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Maturation Phase

• Vascularity decreases
• Decreased number of fibroblasts
• Tensile strength increases

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Collagen ProductionCollagen Degradation
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Skin Grafting Priorities

• Survival
• Function
• Appearance

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Skin Graft Failure

• Inadequate excision
• Excessive bacteria on recipient site
• Serum or blood beneath graft
• Mobility of graft on bed

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Wound ContractionandSkin Grafting
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Factors known to EffectWound Contraction

• Reduction in
• Factor Wound Contraction
• STSG alone 31
• FTSG alone 55
• FTSG Splint 77
• 
  Rudolph, 1980

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Skin Replacements
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Re-Epithelialization

• Begins within 24 hours
• Occurs on surface of wound

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Epidermal Healing

• Contact guidance
• Contact inhibition

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Cardinal Signs of Inflammation

• Redness
• Edema
• Warmth
• Pain
• Decreased ROM

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Hemostatic Events

• Vascular spasm
• Formation of platelet plug
• Fibrin clot

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Cellular Events

• Neutrophils and Monocytes infiltrate
• the area
• Rid site of contaminating bacteria
• Monocytes convert to Macrophages

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Vascular Events

• Transient vasoconstriction
• followed by active vasodilation

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Wound Contraction

• Lag for 5 7 days
• Size does not affect rate
• Location affects amount

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Types of Healing

• Primary
• Secondary
• Tertiary