Burns Lectures Flashcards
there is no greater trauma to the body than what kind of injury?
burns
what should you do if there is a fire?
smoother it, don’t put water on it or try to pick it up
what is the term for the skin coming off a burns wound?
eschar
the darker (more opaque) and more adherent the eschar, the deeper or more superficial the wound?
the deeper the wound
when a burn gets deeper, is it more or less painful?
less painful
what is the most common MOI of burn injuries?
home accidents
almost 1/4 (24%) of all burn injuries occur in …
children bw 1-15 yo
where do most pediatric burns occur?
in the home when unsupervised
where do the hair follicles, sweat glands, and sebaceous glands sit in the skin?
in the dermis
t/f: some of the epidermis extends down into the dermis and wraps around the hair follicles
true
t/f: superficial partial thickness burns can heal on their own with intact hair follicles
true
t/f: full thickness burns can heal on their own
false
what is a burn?
a loss of skin integrity bc of cell exposure to temps that are incompatible with cell life
what are the types of thermal injuries?
flame
scald
contact
what type of burns are contact burns usually?
deep
what are the types of non-thermal burn injuries?
frost bite
electrical
chemical
radiation
how long do burns take to fully express themselves?
12-24 hrs
the severity of thermal and non-thermal burn injuries is related to what factors?
temp to which the skin is exposed
duration of exposure
thickness of the involved skin
what is the thickest skin on the body?
heels/bottom of feet
what is the thinnest skin on the body?
dorsum of hands
what is a epidermal (superficial) burn?
through the epidermis only
what kind of burn is sunburn typically?
superficial burn
what is a superficial partial thickness burn?
a burn through the epidermis and some of the dermis but hair follicles are intact
what are some key signs of a superficial partial thickness burn?
in tact blisters
small shiny dots
epidermal budding
what is a deep partial thickness burn?
burn through the dermis
what is a full thickness burn?
burn through the dermis and into subQ tissue
what burn has VERY adherent aeschar that cannot be easily removed?
full thickness burn
what is a KEY sign of a full thickness burn?
thrombosed veins
what is a subdermal burn?
deepest burn through the subQ tissue into the hypodermis and muscles
what burn has erythematous, is pink/red, and has an irritated dermis?
superficial burn
what burn is bright pink/red/ mottled red, has an inflamed dermis, is erythematous with blanching and brisk capillary refill?
superficial partial thickness burn
what burn is mixed red/waxy white and blanches with slow capillary refill?
deep partial thickness burn
what burn is white (ischemic)/ charred/tan/fawn/mahogany/ black/red (hemoglobin fixation) with no blanching, has thrombosed vessels, and poor distal circulation?
full thickness burn
what burn is charred appearing?
subdermal burn
what burn has no blisters, a dry surface and delayed pain/tenderness?
superficial burn
what burn has intact blisters, moist weeping/glistening surface when blisters removed, is very painful and is sensitive to changes in temp, exposure to air current, light touch?
superficial partial thickness burn
what burn has broken blisters/ wet surface, is sensitive to pressure, but insensitive to light touch or soft pinprick?
deep partial thickness burn
what burn has parchment-like/ leathery/rigid/dry skin is anesthetic, and has body hairs that pull out easily?
full thickness burn
what burn has subQ tissue evident, is anesthetic, has muscle damage, and has neuro involvement?
subdermal burn
what burn has min edema, spontaneous healing, and no scars?
superficial burn
what burn has moderate edema, spontaneous healing, min scarring, and has discoloration?
superficial partial thickness burn
what burn has marked edema, slow healing, and excessive scarring?
deep partial thickness burn
what burn has a depressed area, heals with skin grafting, and leaves scarring?
full thickness burn
what burn has tissue defects, can heal with skin graft/flap, and leaves scarring?
subdermal burn
what types of burns can heal spontaneously?
superficial and superficial partial thickness burns
does a deep partial thickness burn heal fast or slow?
slow
is there scarring with a superficial burn?
nope
what burns requires grafts to heal?
full thickness and subdermal burns
does a superficial partial thickness burn leave scarring?
yes, but minimal
does a deep partial thickness burn leave scarring?
yes, excessive scarring
what are chemical burns?
burns that occur with any substance that causes a chemical rxn with the cutaneous and subQ tissues
the depth of injury with chemical burns is related to what 4 factors?
concentration
duration of skin contact
penetration
quantity of burning agent
t/f: with chemical burns, damage continues until the substance depletes its capacity to damage cellular protoplasm or it’s removed
true
what are the medical interventions for chemical burns?
immediate irrigation with copious amounts of water
tx of systemic toxicity if any
local care of the burn
what is an electrical burn?
a burn that results from the passage of an electrical current through the body after the skin has contacted an electrical source
what is the entrance wound in an electrical burn?
the contact site of the body with electricity
what is the exit wound (ground site) in an electrical burn?
the wound often larger than the entrance wound
is an exit wound always present with an electrical burn?
no
t/f: with electrical burns, much of the damage can be hidden under the intact skin bc of the resistance levels of the tissues in the body
true
what is the PT role in assessing the hidden damage of electrical burns?
testing sensation, ms strength, and pulses bc ms, blood vessels, and nerve are more easily affected than skin
what voltage would cause a low voltage electrical burn?
<1000V
a flash burn is a ____ voltage electrical burn
low
what causes a flash burn?
electric sparks causing direct thermal burns to the skin or through clothes catching fire
what voltage would cause a high voltage electrical burn?
> 1000V
what is a high voltage electrical burn?
a contact burns by entry of electric current into the body through the skin
electrical burns are related to what principles for electricity?
Ohm’s law
Joule’s law
what is Ohm’s law?
electric current is directly proportional to voltage and inversely proportional to resistance
what body tissue has the greatest resistance?
bone
what body tissue has the least resistance?
nerve
order these tissues from most to least resistance: muscle, fat, bone, tendon, skin, nerve, blood vessel
bone, fat, tendon, skin, muscle, blood vessel, nerve
t/f: bone generates more heat than other tissues so it is responsible for causing thermal damage to surrounding tissues
true
what is Joule’s law?
heat is produced when an electrical current meets resistance over time
if an electrical current reaches bone, what happens?
it develops excessive amounts of heat bc of its high resistance
what are the immediate effects of electrical current?
burns
ms damage
cardiac arrythmias (v fib)
acute renal failure
SC damage
vertebral fx
neuro sx
do acute or delayed onset neuro sx have a better px for recovery?
acute onset neuro sx
what are the long term sequelae of electrical injury? (just know a few, I’m not listing them all)
HA
generalized pain
fatigue/exhaustion
frustration
guilt
tremor
joint stiffness
night sweat, fever, chills
ms spasms
pruritis
anxiety
flashbacks
and many more :)
what are radiation burns?
burns that result from radiation
what are friction burns?
burns that result from being dragged
what are inhalation injuries?
pulmonary trauma caused by inhalation of thermal or chemical irritants (mostly chemical, carbon monoxide)
t/f: inhalation injury causes thermal injury to the upper airways creating edema in the upper airways
true
t/f: inhalation injury causes local chemical irritation through the respiratory tract
true
what chemicals often cause systemic toxicity in inhalation injury?
carbon monoxide (CO)
hydrogen cyanide (HCN)
66% of pts with facial burns have what kind of injury?
inhalation injury
mortality increases 20% for pts with burns and ____ injury
inhalation
mortality increases 40% for pts with burns, ____ injury, and _____
inhalation, pneumonia
how are inhalation injuries diagnosed?
through subjective and objective measures
what subjective/objective things help diagnose an inhalation injury?
flame injury
injury in an enclosed space
disability (unable to leave fire site)
facial burns
singed nose hairs
carbonaceous sputum
soot
stridor
carboxyhemoglobin levels
chest CT
fiberoptic bronchoscopy
what is the tx for inhalation injury?
100% O2 ASAP like rocky
t/f: the half life of COHb varies with concentrations of O2 inhaled
true
t/f: the sooner we get 100% O2 to a pt with inhalation injury, the sooner the CO is to dissipate
true
if on room air, what is the half life of COHb?
320 min
if on 100% O2, what is the half-life of COHb?
74 min
what can reduce the half life of COHb to 20 min?
hyperbaric chamber O2
t/f: hyperbaric chamber O2 is the gold standard tx for inhalation injury
false, there is insufficient evidence to support the use of hyperbaric oxygen for tx of pts with CO poisoning bc it can take too long to get to one
t/f: chest PT reduces pneumonia following inhalation injury
true
what are the 3 main purposes of chest PT in rehab with an inhalation injury?
expiratory rib cage compression
postural drainage
cough exercises
what are the burn injury sequelae?
immune system
metabolic
CV system
psych
endocrine
MSK
integ
infection
what are the 3 zones that can be identified concentrically around the center of the burn injury?
zone of coagulation
zone of stasis
zone of hyperaemia
what is the zone of coagulation?
the deepest center of the wound
what is the zone of stasis?
the zone around the zone of coagulation that has a 50/50 chance of staying the way it is or becoming deeper and converting into the zone of coagulation
what is the zone of hyperaemia?
the mostly superficial outer burn rim
what zone of a burn has irreversible tissue damage?
the zone of coagulation
what zone of a burn is characterized by decreased tissue perfusion with tissue that is potentially salvageable?
the zone of stasis
what is involved in the immune response to burns?
a more pronounced inflammatory response compared to non-burn trauma
initial pro-inflammatory response (Th1) from the innate immune system
shift to sustained anti-inflammatory state (Th2)
what are the consequences of altered immune response following burn injury?
increased susceptibility to infections
compromised immune cell fxn
persistent elevation of inflammatory markers
t/f: there is an imbalance bw the innate and adaptive immune responses following a burn injury
true
describe the imbalance bw the innate and adaptive immune responses following a burn injury?
we need a constant innate immune response, but the humoral response overpowers and shuts down the innate immune response
describe the color and smell of a pseudomonas infection
green and sweet smelling
t/f: following a burn injury, there is a non-specific down regulation of the immune system
true
what is the immediate metabolic change following a burn injury?
hypermetabolic state
how long can the hypermetabolic state following a burn injury last?
up to 3 yrs post-injury
hypermetabolism following burns results in what?
sustained loss of ms mass
decreased bone density
high protein degradation
reduced ms mitochondrial fxn
chronic ms weakness
t/f: hypermetabolism affects only severe burn pts
false, it affects both severe and non-severe burn pts
lipolysis results in the increase of what things?
total fat and fat %
lipolysis results in the lose of what things?
body weight
lean body mass
bone mineral content
bone mineral density
what is proteolysis?
protein breakdown that increases 3-4 fold bw 1-3 weeks post-burn
proteolysis leads to what?
a negative protein net balance
why is proteolysis increased post-burn?
it is the body’s way of using its AAs to try and help with the hypermetabolic state
there is a ____ in serum glucose following a burn
increase
there is ____ levels of endogenous insulin following a burn
increased
t/f: pts post burn often have insulin resistance and are more likely to develop DM from their injuries
true
t/f: the more severe burn pts eat, the faster they heal
true
nutritional requirements following a burn injury are proportional to what factors?
TBSA burn, age, and weight of the pt
burn pts may require up to how many calories per day?
4000-5000
do children with burn injuries require more or less calories than their adult counterparts with burns?
more calories
what are the CV responses 12-48 hrs post-burn?
increased capillary permeability throughout the entire body
vasoconstriction
increased protein leakage
what is fluid resuscitation?
fluids administered via IV over 24-72 hrs
with fluid resuscitation, we keep adult urine output ____ CC/hr
30-60
what pts get fluid resuscitation?
adults with >20% TBSA burns
children with >10% TBSA burns
pts with pre-existing medical conditions
what are some CVP consequences of burns?
increased HR, cardiac output, and capillary permeability
decreased myocardial contractility, hypotension, and end organ hypo-perfusion
pulmonary dysfxn, bronchoconstriction, and resp failure
what is a severe CV response to burns that causes vascular, neuromuscular, and respiratory compromise?
compartment syndrome
what are red flag signs to look for in CV responses to burns that may indicate compartment syndrome?
diminished pulses and weakness
what are signs to look for in CV responses to burns that may indicate compartment syndrome?
diminished pulses
weakness
change in temp
edema
signs of ischemia
what are the most common contractures that develop from burns
hip IR, flexion, and abduction
cervical flexion
shoulder protraction
what results in contracture development post burn?
pain
position of comfort
ms weakness
what are the principles of tissue (skin) healing?
the position of comfort will be the position of contracture
the location of the contracture depends on the location/depth of the burn, gravity, and pt compliance
the location of the contracture depends on what factors?
the location of the burns
depth of the burns
gravity
pt (non)compliance
t/f: deeper burns are more likely to develop contractures
true
what are the mental health consequences of burns?
PTSD and depression (not important how severe the incident was)
does the epidermis regenerate or repair?
regenerates
intact epithelium in epidermal healing attempts to cover the wound through what methods?
miosis and movt of the cells from the basal layer
t/f: moving epithelial cells always maintain contact with normal epithelium
true
what causes the dryness and itching in burns?
the damage to sebaceous glands
what is a sign that the wound can heal through epidermal healing?
epidermal buds
does the dermis heal through regeneration or repair?
repair
what are the 3 phases of scar formation?
inflammatory phase
proliferative/fibroblastic phase
maturation phase
what causes hemostasis in phase one of dermal healing?
vasoconstriction and platelet aggregation
what is involved in the inflammatory phase of dermal healing?
release of histamine leading to increased capillary permeability and vasodilation
phagocytosis
what is involved in the fibroblastic (proliferative) phase of dermal healing?
accumulation of fibroblasts in the wound
collagen production
neovascularization
what is the difference bw a hypertrophic scar and a keloid?
ahypertrophic scar stays within the og wound boundaries, while a keloid goes outside of these boundaries
what causes a hypertrophic scar in burns?
the collagen is laid out in disorganized bundles and myofibroblasts cause the tissue to contract and elevate
imbalance bw collagen production and lysis
rich blood supply
what is scar maturation in dermal healing? how long does it last?
the period during which the scar continues to change in form, bulk, and strength for 1-2 yrs
what are the indications for surgery with burns?
partial-full thickness injury
crosses joints
potential to limit fxn
large area
what are the types of permanent grafts?
autografts
cultured skin
what is the only type of temporary graft?
homograft (allograft)
what are the 2 types of autografts that can be used in burns?
full thickness autograft
split thickness autograft
what is a full thickness autograft?
a graft using all the dermis from the donor site
which autograft results in less scarring?
full thickness autograft
does the donor site heal on its own with a full thickness autograft?
no, it needs a split thickness graft
what is a split thickness skin graft (STSG)?
a meshed skin graft that doesn’t use the entire dermis of the donor site
t/f: we can harvest from the donor sites over and over again with STSGs
true
when would we use a STSG?
for a large area
for a dirty wound so that exudate can come through
does the donor site heal on its own with STSGs?
yes
what is an allograft/homograft?
cadaver skin
most often, allografts/homografts are used for what burns?
burns that are 50% or greater
what are the indications for allograft/homograft?
temporary biologic coverage (reduce pain, decrease water/electrolyte/protein loss, stimulate vascularization, protect wound from bacterial contamination, promote dermal matrix)
dressing for partial thickness wounds
wound bed prep for autografting
what are the alternative methods for wound closure?
xenografts
artificial skin substitutes
what is a xenograft?
a graft obtained from an unrelated species
are xenografts used very often in the US anymore?
nope
what are artificial skin substitutes composed of?
biological, synthetic, and biosynthetic materials
what do artificial skin substitutes do?
provide scaffold and substitutes for the extracellular matrix
framework for neovascularization
cell adhesion
proliferation
is there motion restrictions for the donor site
nope
how many days of post-op immobilization is there for the graft site?
3-5 days
bc pts have to be immobilized for 3-5 days post graft, what do we as PTs have a role in doing?
putting them in a position of fxn
what is involved in phase 1 (initial assessment and triage) of medical tx of burns?
stop the burning process
primary survey
secondary survey
begin fluid resuscitation
what is the primary survey in burns assessment?
airway, breathing, and circulation assessment
what is the secondary survey in burns assessment?
assessment of other injuries, estimating % TBSA
with fluid resuscitation, how do we calculate the initial fluid rate?
either 2-4 mL/kg per 24 hrs to estimate 24 hr volume or using the rule of tens
when does fluid resuscitation occur?
0-48 hrs post injury
what are the phases of medical tx of burns?
phase 1: initial assessment and triage
phase 2: fluid resuscitation
phase 3: burn wound care and coverage
what is involved in burn wound care and coverage?
use of topical antimicrobial creams or dressings to prevent infection
surgical debridement, burn wound excision, and autografting
optimize conditions for wound healing
cleansing, debridement, dress/bandage
when is the most ideal time for PT/OT to get ROM measurements for a burn pt?
when they are getting bathed for wound cleansing
what debridement may be used for burns?
mechanical
enzymatic
sharp
biologic
what form of debridement is the best source of wound care due to the fact that it only affects the necrotic tissue and doesn’t disrupt the good tissue?
biologic debridement (maggots)
why would an escharotomy be done?
to prevent compartment syndrome
why does compartment syndrome occur post-burns?
bc the increased vascular permeability in burns leads to increased fluid compressing the vasculature when the skin can’t stretch anymore
if an escharotomy doesn’t work, what can be done next?
faschiotomy
what critical medical intervention must begin immediately after admission?
an eval for an escharotomy
fluid resuscitation
when is fluid resuscitation indicated?
in adults with >20% TBSA burns
kids with >10% TBSA burns
anyone with comorbidities
why is it crucial to intubate right away with an inhalation injury?
bc the throat will swell, then an emergency trach tub has to be placed to get oxygen
faster O2=shorter 1/2 life of CO
what is the PT role in prevention of compartment syndrome?
recognizing the s/s (weakness and decreased pulses)
an eval of burns should be done within ___ hrs of admission
24-48
what is involved in rehab management in the acute phase?
eval
assess the burns
anticipate fxnal and cosmetic deformities
design appropriate rehab program
what is involved in the CVP systems review?
BP
RR
HR
pulse
SpO2
Edema measurement
how is edema often measured in acute care?
observation BL of min, mod, or severe edema in one side compared to the other
what is involved in the integ systems review?
observation
location/body diagram
describe wound appearance
what things do we need to describe about the wound?
tissue color
eschar/exudate color and texture
presence of epidermis
presence of granulation tissue
what is involved in the MSK systems review?
ROM and strength
what pain scale is more commonly used in pediatric populations?
Wong Baker scale
what pain scale is more commonly used in adult populations?
NPRS (0-10)
t/f: immobilization of joints leads to stiff joints
true
t/f: when testing mobility, we should see what the pt can do first
true
what should we note about a pt’s mobility ability?
how long it takes
how much effort it takes
how much assistance they need
what their VS response is
what is the issue with a patient being in ER at the LEs?
it compresses the fibular head and the common peroneal nerve with can lead to foot drop
what are some interventions in acute care?
pt instruction
airway clearance
assistive technology
biophysical agents
fxnal training
integ repair/protection
manual therapy
motor fxn training
ther ex
when should a positioning program begin?
on the day of admission
what are the goals of a positioning program with burns?
minimize edema
prevent tissue destruction
maintain soft tissues in an elongated state
preserve fxn
what is the position that a joint should be put into?
opposite of the anticipated contracture based on eval of the wound distribution and depth
what is the most common deformity of the anterior neck?
flexion
what is the motion to be stressed in positioning for flexion neck contracture?
hyperextension
what is the most common deformity of the shoulder/axilla?
adduction and IR
what motions need to be stressed in an adduction/IR shoulder/axilla contracture?
abduction, flexion, and ER
what is the most common deformity of the elbow?
flexion and pronation
what motions need to be stressed in the elbow for flexion/pronation contracture?
extension and supination
what is the most common deformity of the hand?
claw hand (intrinsic minus)
what motions need to be stressed in the intrinsic hand deformity?
wrist extension, MCP flexion, PIP/DIP extension, thumb abduction
what are the most common deformities of the hip/groin?
flexion, adduction
what motions need to be stressed with a hip flexion/adduction contracture?
all motions, esp hip ext and abduction
what is the most common knee deformity?
flexion
what motion needs to be stressed in a knee flexion contracture?
extension
what is the most common deformity of the ankle?
PF
what motions need to be stressed in a PF contracture?
all motions, esp DF
t/f: splints should be fabricated for pts ONLY if ROM or fxn would be lost w/o them
true
what are the goals of splinting?
prevention of contracture
maintenance of ROM achieved during exercise session or surgical release
reduction of developing contractures
protection of a jt or tendon
to reduce the overall pain experience
what are the different options for wearing schedules with splints?
night
resting
continuous
t/f: splinting would be continuous for several days following skin grafting
true
t/f: splints are meant to be a therapy in and of themselves
false, they are intended to serve as adjuncts to the therapy program until full active motion can be achieved
if a pt has 25% TBSA superficial partial thickness burns over BUE, neck, and trunk and they are cooperative and motivated, do we splint them? why or why not?
no bc the burns are superficial partial thickness which will have minimal scarring due to minimal dermal involvement
if a pt has 8% TBSA sclad burns in BL hands with decreased AROM by half and they are inconsistent with exercise, will we splint them? why or why not?
probably at night and maybe at rest during the day bc we want them using their hand as much as possible
if a pt has 20% TBSA flash burns BLE and is able to achieve full knee extension after exercise and stretching, do we splint them? why or why not?
yes, splint at rest to maintain their ROM gained with exercise
what is involved in ther ex in acute rehab of burns?
ROM
active exercise
t/f: ROM in the area of unhealed burns can be very painful
true
when does active exercise begin?
on day of admission
what is an opportune time to exercise to be done with burns pts?
during dressing changes
why is during dressing changes a good time to do our exercises?
bc the burns wound is visible and the therapist can monitor the wound during movt
t/f: in the presence of recent skin grafting, the timing of reintroduction of active and passive exercise in the area is variable, depending on surgeon protocols
true
t/f: PNF patterns are less painful for burns pts
true
hypermetabolism, skeletal catabolism, and prolonged bed rest in burns leads to what declines in physical fitness?
decreased aerobic capacity
decreased lean body mass
decreased pulmonary fxn
decreased strength
exercise may consist of _____, ______, or other resistive training devices
isokinetic, isotonic
t/f: exercises that will stress the CV system are encouraged with burns pts
true
what exercises can we use to stress the CV system with burns pts?
walking
cycling/rowing/ergometry/treadmill/stairs
interactive video games
t/f: ambulation activities should be initiated as soon as possible
true
post skin graft, how should the LE be wrapped?
in elastic bandages in a figure 8 pattern to support the new grafts and promote venous return
t/f: systematic reviews and meta-analysis shows that pts with delayed ambulation where found to have increased pain levels at rest and when ambulating and possible increased infection rates
true
when a pt is severely orthostatic, what can we use to get them accommodated to upright?
tilt table
during the critical phase of burns, what are the psycho-social concerns?
preoccupation with their own somatic disorders
may experience nightmares and depression
during the stabilization phase of burns, what are the psycho-social concerns?
more confidence in their survival, but depression persists, anxiety regression is more evident and pts are usually more demanding
during what phase of burns are the pt behaviors more reflective of their true personality and the pts get more involved in their own tx and welfare?
recovery
during the pre-discharge phase of burns, what are the psycho-social concerns?
ambivalence about discharge
separation anxiety
bouts of depression/euphoria
what are some interventions involved in post-acute care with burns?
pt instruction
airway clearance
assistive technology
biophysical agents
fxnal training integ repair/protection
manual therapy
motor fxn training
ther ex
t/f: superficial partial thickness burns usually don’t scar and heal on their own in 10-14 days
true
what burns scar the most?
deep partial and full thickness burns
t/f: early healing/grafting decreased scarring
true
do children or the elderly scar more?
children
t/f: you can predict the severity of scarring based on race
false
what phase of scarring is characterized by a red, raised, rigid scar
immature scarring
what phase of scarring is characterized by a pink, raised, rigid scar?
semi-mature scarring
what phase of scarring is characterized by a pale, plantar, and pliable scar?
mature scarring
what scar would move as one unit when we try to mobilize it?
an immature scar
during what scar maturation phase would we want to do our interventions?
during the immature and semi-mature scar phases
during what scar maturation phase would our interventions be ineffective?
during the mature scar phase
what are the 4 categories of the Vancouver Scar Scale?
pigmentation
vascularity
pliability
height
what is 0 for pigmentation on the Vancouver Scar Scale?
normal pigmentation
what is 1 for pigmentation on the Vancouver Scar Scale?
hypopigmentation
what is 2 for pigmentation on the Vancouver Scar Scale?
hyperpigmentation
what is 0 for vascularity on the Vancouver Scar Scale?
normal
what is 1 for vascularity on the Vancouver Scar Scale?
pink
what is 2 for vascularity on the Vancouver Scar Scale?
pink to red
what is 3 for vascularity on the Vancouver Scar Scale?
red
what is 4 for vascularity on the Vancouver Scar Scale?
red to purple
what is 5 for vascularity on the Vancouver Scar Scale?
purple
what is 0 for pliability on the Vancouver Scar Scale?
normal
what is 1 for pliability on the Vancouver Scar Scale?
supple (flexible w/min resistance)
what is 2 for pliability on the Vancouver Scar Scale?
yielding (giving away to pressure)
what is 3 for pliability on the Vancouver Scar Scale?
firm (inflexible, not easily moved, resistant to manual pressure)
what is 4 for pliability on the Vancouver Scar Scale?
banding (rope-like tissue that blanches with extension of the scar)
what is 5 for pliability on the Vancouver Scar Scale?
contracture (permanent shortening of scar producing deformity or distortion)
t/f: the Vancouver Scar Scale has color scales for light and dark skin
true
how is vascularity measured in the Vancouver Scar Scale?
use clear plastic to apply pressure to the area then observe the return of color
a ____ scar will bridge a jt and continue to contract until it meets an opposing force
hypertrophic
what is the gold standard tx for hypertrophic scarring?
pressure therapy
what is pressure therapy for hypertrophic scars?
constant and controlled pressure (slightly greater than that of capillary pressure of 23 mmHg)
RCTs show that pressure therapy results in significant differences in what? what does it not show a difference in?
thickness, brightness, redness, pigmentation, and hardness
no effect on vascularity
what is a key effect of pressure therapy?
decreasing vascularity which in turn decreases myofibroblast activity and therefore collagen synthesis
what is the typical pressure for pressure therapy in hypertrophic scarring?
> 23 mmHg
how long is pressure therapy applied for throughout the day?
24 hrs/day for about a yr until scar has matured
when is pressure therapy initiated?
when the wound are healed/closed
t/f: the garment in pressure therapy should fit tightly and slightly blanch the skin
true
pts should have at least how many garment sets for pressure therapy?
2
what are the various methods of applying pressure?
ace bandages
custom made pressure garments
pre-fabricated garments (tubigrip)
self-adhesive wraps (coban)
inserts
splints
transparent face masks
what kind of stretch should be used for scars?
a static low load long duration stretch (blanching on stretch)
t/f: applying a stretch to the tissues facilitates collagen fiber alignment
true
can we use serial casting for scars?
yes!
can we use paraffin for scars?
yes!
what is scar massage effective for?
decreasing scar thickness
depression
pain and scar characterisitics (vascularity, pliability, scar height)
decreased pruritis (itching)
why wound we use or not use US for scarring?
we could use to to heat tissue with restricted ROM
but we also may not choose to use it bc we don’t want to heat tissue with excessive vascularity
t/f: hands are one of 3 of the most common sites for contracture development
true
t/f: loss of fxn of the hands has no real effects on the pt
false, loss of hand fxn can be devastating on life roles
what is the typical contracture position of the hands?
intrinsic plus (wrist flexion, MCP extension, IP flexion, thumb adduction)
what position do we want to splint the hands in to prevent intrinsic minus positioning?
intrinsic plus (wrist extension, MCP flexion, IP extension)
when there are HEALTHY exposed tendons, what ROM can we do?
ISOLATED jt ROM
t/f: no full fisting is done in the presence of questionably viable extensor tendon mechanism and unhealthy exposed tendon or jt
true
when would reconstructive options be considered for hypertrophic scarring?
when the scars are matured and all else has failed after our tx
what is a z plasty for hypertrophic scarring?
excision of the scar and closure in a “z” pattern
what is a muscle flap reconstruction for hypertrophic scarring?
microvascular transplantation of the muscle and arteriovenous bundle to the site of a wound
when is a muscle flap reconstruction chosen for hypertrophic scarring?
for areas with weak blood supply
what is a tissue expander?
when a balloon is placed in the skin and slowly expanded over time, then extra skin is placed over the scar/wound
what is HO?
the formation of new bone in tissues that normally don’t ossify (soft tissue surrounding a jt, within a jt capsule and ligs, or a bony bridge across a jt)
what is the most common location of HO?
posteromedial elbow
what is Steven Johnson Syndrome/Toxic Epidermal Necrolysis?
a dermatologic disorder characterized by separation of the epidermis and dermis with subsequent skin loss (epidermis sloughs off leaving an exposed dermis)
t/f: the etiology behind Steven Johnson Syndrome/Toxic Epidermal Necrolysis is well defined
false
what are possible causes of Steven Johnson Syndrome/Toxic Epidermal Necrolysis?
drugs
infection/disease
what drugs can cause Steven Johnson Syndrome/Toxic Epidermal Necrolysis?
anticonvulsants
acetaminophen
meds containing sulfur when allergic to sulfur
t/f: Steven Johnson Syndrome/Toxic Epidermal Necrolysis is VERY painful
true
how long does it typically take Steven Johnson Syndrome/Toxic Epidermal Necrolysis to heal?
10-14 days
what are the clinical manifestations of Steven Johnson Syndrome/Toxic Epidermal Necrolysis?
painful skin rash or ulcerations
appears like a superficial partial thickness burns
mucosal involvement
re-epithelialization within 14 days w/o scarring or infection
Steven Johnson Syndrome/Toxic Epidermal Necrolysis has a mortality rate of 25-100% most commonly due to what?
sepsis
what is involved in medical management of Steven Johnson Syndrome/Toxic Epidermal Necrolysis?
discontinuation of causative drug
meticulous wound care
nutritional support
pulmonary care
pain management
what is involved in rehab of Steven Johnson Syndrome/Toxic Epidermal Necrolysis?
early ROM and fxnal activities
CPT, swallowing evals, and splinting as needed
is scar management usually necessary with Steven Johnson Syndrome/Toxic Epidermal Necrolysis?
no
when would we use scar management for Steven Johnson Syndrome/Toxic Epidermal Necrolysis?
if infection causes it to convert to a deep partial thickness wound
what is necrotizing fasciitis?
a rapidly progressive infection that destroys deep soft tissues including ms fascia and overlapping subQ fat
strep A
necrotizing fasciitis is commonly seen in what pt population?
pts with kidney failure
how would necrotizing fasciitis wounds be treated?
with a wound vac changed every 3-5 days
are kids and adults with burns treated the same?
NO!!!
