Epidemiology. Burn Rehabilitation. Epidemiology. Epidemiology. United States. United States Cause of injury. Incidence has declined
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1 Burn Rehabilitation Peter Esselman, MD Professor and Chair Department of Rehabilitation Medicine University of Washington Epidemiology United States 450,000 burn injuries/year in USA that receive medical care 40,000 hospital admissions per year 3,400 deaths per year 70% Male, 30% Female Survival of those admitted to burn center 96.6% Esselman, Review Course American Burn Association Fact Sheet 2013 Miller SF, J Burn Care Res 27: , 2006 Esselman, Review Course Epidemiology United States Cause of injury 32% fire/flame 34% scald 9% contact with hot object 3% chemical 4% electrical 7% other causes Miller SF, J Burn Care Res 27: , 2006 Burn Incidence and Treatment in the US: 2013 Fact sheet. Available at Esselman, Review Course Epidemiology Incidence has declined Prevention Mortality has declined 1984 LD 50 ~ 65% TBSA burn Current LD 50 ~ 80% TBSA burn Increased mortality risk Inhalation injury Age Esselman, Review Course
2 Belgian Outcome Study ( data) Belgian Outcome Study ( data) British J Surg, 2009;96: Esselman, Review Course British J Surg, 2009;96: Esselman, Review Course Anatomy of Normal Skin Dermal appendages have an important role in healing of burn wounds due to epidermal tissue located in the dermis. Esselman, Review Course Esselman, Review Course
3 Depth of Burn Injury Superficial Partial Thickness Full Thickness All are minor except in very young (<18 months) or elderly Cause Sunburn, ultraviolet exposure, short flash Healing 3 7 days Superficial Burns Esselman, Review Course Esselman, Review Course Partial Thickness Burn Superficial involves epidermis, papillary dermis, blisters Deep involves reticular dermis Significant burn if >15% TBSA in adults or >10% in children Skin red, blanch with pressure, mottled white Healing 7 21 days if superficial, days if deep, may need grafting if deep or on head/neck or hand Painful Esselman, Review Course Full Thickness Burn Significant burn unless very small area Extend through the dermis and into the subcutaneous fat All skin appendages are damaged, therefore burns can only heal from periphery Skin is dry, with eschar Healing Large areas require grafting Less painful at site of burn Esselman, Review Course
4 Assessment of Burn Size Rule of 9s (11 segments of 9%) Head 9% Trunk: Anterior 18%, Posterior 18% Upper Extremity: Anterior 4.5%, Posterior 4.5% Lower Extremity: Anterior 9%, Posterior 9% Perineum 1% Only Partial and Full thickness burns included Esselman, Review Course Esselman, Review Course Esselman, Review Course Esselman, Review Course
5 Criteria for Burn Center Transfer Partial thickness burn > 10% TBSA Third degree burn in any age group Burns to areas at risk for complications Hands, feet, face, genitalia, buttocks, major joints Inhalation injury Electrical burns, including lightning injury Chemical burns Acute Burn Complications Inhalation injury Carbon monoxide exposure Upper airway obstruction Chemical pneumonitis Wound Infection Topical agents Silver sulfadiazine (Silvadene) Systemic antibiotics only as needed Hypermetabolism, need for nutritional support Purdue GF. Phys Med Rehabil Clin N Am Vol 22, Esselman, Review Course Esselman, Review Course Burn Wound Care Debridement Remove eschar and necrotic tissue Early excision and grafting of deep partial thickness and full thickness burn injuries Pain management Narcotics Hypnosis and Virtual Reality Kagan RJ et. al. J Burn Care & Research 34:e61-e79, 2013 Esselman, Review Course Esselman, Review Course
6 Biologic Dressings Xenograft Pig skin Provide barrier, wound covering Allograft Human cadaver skin Rejection occurs after 2 3 weeks Provides wound coverage when autografting not clinically indicated or inadequate autograft donor sites Esselman, Review Course Skin Substitute Products Epidermal equivalents Cultured epidermal autografts (CEAs) Limited applications Allogenic Skin Equivalents Cultured cells, cellular skin substitutes Limited commercial availability Nyame TT et al, Clinical applications of skin substitutes. Surg Clin N Am 94(2014) Esselman, Review Course Skin Substitute Products Dermal Templates Integra Collagen dermal matrix (bovine, shark) Synthetic dermis vascularized from wound bed Thin split thickness autograft placed on top of vascularized Integra after days Autografts Split Thickness Skin Graft Mesh graft Sheet graft face, neck, hands, joints Full thickness skin graft Donor site Nyame TT et al, Clinical applications of skin substitutes. Surg Clin N Am 94(2014) Esselman, Review Course Esselman, Review Course
7 Split thickness skin graft meshed 25 Esselman, Review Course Esselman, Review Course Split thickness skin graft sheet Esselman, Review Course Esselman, Review Course
8 Full Thickness Skin Graft Graft includes entire dermis Used only for small areas such as eyelid, lip and tip of nose Provides for good cosmetic result Donor site heals from edges Donor Sites Donor sites are partial thickness injuries Typically they heal on their own with little to no scarring They are painful Esselman, Review Course Esselman, Review Course Healing Donor site Complications of Burn Injuries Hypertrophic Scar Contractures, joint deformities Heterotopic Ossification Amputations Neurologic injury Esselman, Review Course Esselman, Review Course
9 Hypertrophic Scarring Clinical picture Red, raised and rigid Contracts and distorts surrounding tissue Progression Peak scarring usually occurs at 4 6 months postinjury Maturation varies from 6 months to 2 years Esselman, Review Course Esselman, Review Course Esselman, Review Course Esselman, Review Course
10 Hypertrophic Scarring Who is at risk? Patients with wounds that take longer than 3 weeks to heal Children have higher likelihood of scarring compared to adults Patients with more skin pigment tend to scar more Esselman, Review Course Esselman, Review Course Hypertrophic Scarring Treatment Identify persons at risk Contractile forces treated with stretching Raising forces treated with pressure Pressure garments Pressure wraps Splints Hypertrophic Scarring Pressure garments and wraps Used to flatten hypertrophic areas and provide vascular support Worn at all times except while bathing Expensive Many companies make ready made and custom fit garments Esselman, Review Course Esselman, Review Course
11 Esselman, Review Course Esselman, Review Course Pressure garment effectiveness Scar measurement Vancouver Scar Scale Thickness, hardness, color Anzarut, 2007 Meta analysis Pressure garment therapy does not appear to alter global scar scores. there is insufficient evidence to support the widespread use of pressure garment therapy Esselman, Review Course Esselman, Review Course
12 Pressure garment effectiveness Engrav, 2010 Wounds treated with compression were significantly softer, thinner, and had improved clinical appearance. Benefit restricted to patients with moderate to severe scarring. Contractures and Joint Deformities The most significant problem in burn rehabilitation Treatment Positioning Splinting Range of Motion, Stretching Esselman, Review Course Esselman, Review Course Positioning Prevent contractures The position of comfort is the position of contracture Prevent edema Prevent complications Further skin breakdown Neurologic injuries Splinting Immobilize a joint after grafting and/or apply pressure to a new graft Prevent deformity Place joint in functional position or position opposite the expected deformity Stretch soft tissue Static splint Dynamic splint Esselman, Review Course Esselman, Review Course
13 Esselman, Review Course Esselman, Review Course Exercise & Stretching Short frequent sessions better than long sessions Pain medications or non pharmacologic pain management necessary before therapy sessions Paraffin may be useful Esselman, Review Course Esselman, Review Course
14 Neck Burns Flexion contractures Place neck in extension or hyperextension Avoid use of pillows Neck splint Face Burns Eyes Ectropian (eversion of lower lid) Lips Lower lip eversion Mouth Microstomia (decreased opening of mouth) Esselman, Review Course Esselman, Review Course Axilla Burns Full motion difficult to obtain in deep burns Frequent exercise is very important Axillary or airplane splint Position in 90 deg abduction with deg horizontal adduction Risk of brachial plexus injury May need surgical release Esselman, Review Course Esselman, Review Course
15 Esselman, Review Course Esselman, Review Course Esselman, Review Course Esselman, Review Course
16 Elbow Burns Flexion contractures with forearm pronation common Risk of heterotopic ossification Heterotopic Ossification Elbow joint commonly involved Severe upper extremity burns Prolonged immobilization Potential cause of ulnar neuropathy May cause significant disability May need surgical resection Esselman, Review Course Esselman, Review Course Esselman, Review Course Esselman, Review Course
17 Hand Burns Elevation to prevent edema Position in Wrist extension MCP flexion PIP and DIP extension Thumb palmar abduction Static and dynamic splinting Consider pinning to preserve function Esselman, Review Course Esselman, Review Course Esselman, Review Course Esselman, Review Course
18 Esselman, Review Course Esselman, Review Course Esselman, Review Course Esselman, Review Course
19 Esselman, Review Course Esselman, Review Course Esselman, Review Course Esselman, Review Course
20 Hand Burn Complications Claw Hand Deformity Esselman, Review Course Esselman, Review Course Hand Burn Complications Mallet deformity Injury to terminal slip of extensor tendon with loss of DIP extension Esselman, Review Course Esselman, Review Course
21 Hand Burn Complications Boutonniere Deformity Injury to the extensor tendon at the level of the PIP joint DIP hyperextension with PIP flexion Esselman, Review Course Esselman, Review Course Hand Burn Complications Swan neck deformity PIP hyperextension and DIP flexion due to scarring/contraction of dorsal hand burns Esselman, Review Course Esselman, Review Course
22 Hand Burn Complications Syndactyly loss of dorsal web spaces Esselman, Review Course Esselman, Review Course Esselman, Review Course Esselman, Review Course
23 Esselman, Review Course Esselman, Review Course Lower Extremity Burns Contractures Knee flexion Ankle Plantarflexion Esselman, Review Course Esselman, Review Course
24 Esselman, Review Course Esselman, Review Course Management of Amputations Complicated problem due to Fragile skin Contractures Decreased sensation Pain Esselman, Review Course Esselman, Review Course
25 Esselman, Review Course Esselman, Review Course Esselman, Review Course Esselman, Review Course
26 Esselman, Review Course Esselman, Review Course Esselman, Review Course Esselman, Review Course
27 Neurologic injuries Peripheral nerve injury in up to 30% of patients with burn injuries Focal Peripheral Nerve Injuries Mononeuropathy Direct thermal injury Compartment syndrome Dressings Stretch/positioning Brachial Plexus stretch injury Mononeuritis multiplex Reported in up to 56% of patients diagnosed with neuropathy Esselman, Review Course Esselman, Review Course Peripheral Neuropathy Potential causes Metabolic Nutritional Uremia Drug induced Sepsis with multi organ failure Neurotoxin Electrical injuries 4% of all admissions to burn units Low voltage less than 1,000 volts High voltage greater than 1,000 volts Over 50% of electrical injuries occur at work Esselman, Review Course Esselman, Review Course
28 Electrical injuries Risk of Cardiac arrest Amputations Major limb amputation in 35% of high voltage injuries Peripheral nerve injury Brain and spinal cord injury Electrical injuries Peripheral Neurologic injury caused by Direct electrical injury to nerve Vascular arterial thrombosis or vasospasm Heat generated by current Deep tissue injury and compartment syndrome Muscular contractions Esselman, Review Course Esselman, Review Course Electrical injuries Neuropsychological Impairments Cognitive deficits documented even when current flow did not pass through head and without loss of consciousness or cardiac arrest High rate of psychiatric diagnosis Esselman, Review Course
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