StudyGuideExam4 Flashcards
Where do most burns occur in the house and why?
- Kitchen most frequent area where newborns to 4 years old as well as those over 75 are injured
What is debridement?
- The removal of foreign material, dead or damaged tissue in a wound
Mechanical
soft (gauze pads that are wet) or sharp (tweezers)
Enzymatic
topical ointments
Surgical
perform by Dr under anesthesia
o Both hydrotherapy and debridement are performed at least once a day
Pull off gauze in the water
- Hydrotherapy – use of water in a tub or running water for wound cleansing and debridement
o Water temp set at 100 deg F
Neck- flexion
correct- extension
No Pillow and towel roll
Shoulder- add and int rotation
Abd and Neutral Rotation (Arm troughs, pillows, splints)
Elbow- Flexion
Correct- extension
Arm troughs, pillows, splints
Wrist- Flexion
Extension- Splint or gauze
Hand= intrinsic minus
Intrinsic plus (splint or gauze
Hip (flexion and ext rot)
Neutral (No pillow under knees)
Neutral with pillows
Knee (Flexion
Extension (no pillow under knees and splint
Ankle (plantar Flexion)
Neutral- splint or foam wedge
Types of Grafts
o Autograft – skin from self
o Homograft/allograft – skin from cadaver
o Xenograft – skin from an animal i.e. porcine
o CEA (cultured epithelial autograft) – biopsied skin grown in lab
o Integra – dermal replacement (requires a graft following Integra take)
Sheet vs Meshed Graft
- Sheet graft is more cosmetically appealing (usually on face and hands)
- Sheet graft requires a larger donor site
- Meshed graft can be expanded from 2:1 up to 6:1
- Meshed graft has a waffle like appearance
Know about nutritional needs of burn survivors
- Patients need 3 times the normal protein intake
- No free water- you need them to take in as many calories as they can
- Eschar – protein secreted through hair follicles that need to be removed
ROM
- ROM should be performed every day – contractures can form in 1-3 days
- Patients may require several sessions due to fatigue or more involved areas will need 2 times a day (common with hand burns)
- It’s best if performed during the bathing procedure when bandages are removed
- ROM is usually extremely painful. It’s a learned skill of knowing what needs to be pushed to gain movement and what may be detrimental
- Pain control is a team effort
When to Perform AROM
- As soon as the patient is alert
- Helps with strengthening
- Gives patient control over their care
- Provides them with activities they can do on their own when therapist is not available
When to perform AAROM
- AAROM can be performed by patient or therapist
- If patient is alert, AAROM can be by their own body or an object i.e. wall (wall slides, pulleys)
- The therapist can help when the patient cannot complete the arc of motion due to pain, weakness or fatigue
When to perform PROm
- When the patient is not alert
- This can include under anesthesia, patients given paralytics
- Caution must be used to not damage structures i.e. joints since the patient cannot respond to pain
WHEN TO PERFORM RESISTIVE EXERCISES
- UE diagonals can be used
- Actual weight lifting or heavy work activities should be delayed until the patient is in compression
- Caution should be used to watch for bleeding, breakdown or edema
WHEN TO PERFORM RESISTIVE EXERCISES
- UE diagonals can be used
- Actual weight lifting or heavy work activities should be delayed until the patient is in compression
- Caution should be used to watch for bleeding, breakdown or edema
Precautions with ROM and Exercise: Edema
o Hand- rupture of extensor hood mechanism
o Elbow – damage to ulnar nerve
o Ankle – damage to peroneal nerve
Precautions with ROM and exercise: other
• Medical equipment
• Exposed tendons
• New autograft sites or unstable/fragile autograft sites
• Neuropathies
• IVs
• Exposed joints
• Associated injuries
• Cellulitis
• Heterotopic ossifications – a sudden dramatic decrease in ROM with specific joint pain, only perform AROM until surgically removed
• Escharotomy – an incision with a scalpel through eschar down to subcutaneous tissue, continue ROM but without dressings to view any signs of wound stress, no ambulation if on legs
Fasciotomy
Pressure garments : function
- Control hypertrophic scarring
- Promotes healing
- Assists with venous return
Indications for pressure therapy
- 2nd or 3rd degree burns
- Can initiate with minimal open areas (can still have bandages on)
- Measure for custom garments after temporary compression has been used
- Garments are worn 23 ½ hours a day until scars are mature
Types of temory compression
Ace wraps ■ Compressogrip/tubigrip
Support hose ■ Foam neck collars
Coban ■ Isotoner gloves
Types of custom compression
- Nylon/spandex blend of material with 25-30 mmHg of pressure graded into the garment
- Increase pressures are available for special needs
- Garment details – fit, inserts (foam, otoform, silicone)
- Features – zippers, velcro, linings, soft/regular/heavy material, contracture seams
- Garments must be worn 23 ½ hours a day
- Inserts can be placed in the garments to provide a better fit
Complications and progression: Mature scar
o Fades to approx normal skin color
o Soft in texture with an elastic quality
o Scars remain active for several months to a year or longer
Complications and progression: immature scar
o Hyperemic (erythema) – red to purple in color indicating increased vascularization
o Pruritis – itching
o Decreased pliability – not supple, unyielding
o Hypertrophic – excessive production or collagen fibers that assumes a disorganized orientation producing a raised irregular appearance and inelastic quality
o Keloid – hypertrophic scar that has exceeded beyond the borders of the original scar
Complications and progression: Blisters
Inadequate pressure – most often on donor sites
Bumping or shearing
Resistance without compression
Infection – look for redness, pustules, pus
Rash
o Can be caused by:
Continued use of medication when healed
Overuse of oily lotions (Elta)
Detergent reactions
Shearing/Bumping
o Educate patient about skin frailty
o If occurs patient can apply bandaid or dressing with ointment to keep moist
Dry Scabs
o Encourage to keep dressings on until healed
o Scabs slow healing and increase scarring
Hypertrophic scarring
o Increase pressure, increase scar massage and silicone use
Thermal
- Types: flame, scalding, thermal contact
- Temperature causes direct damage to the skin and sometimes the underlying tissue
- Thermal common with children and elderly – watch patterns for abuse
- Flame patterns vary and may involve inhalation in enclosed areas
Chemical
caused by an acid, alkali, or organic compound
• Severity depends on the agent, concentration volume and duration of exposure
• Sporadic pattern
• Know the chemical to neutralize burning process
Electrical
- Caused by contact with high voltage or low voltage electricity or lightning strike
- High voltage (power lines) causes underlying injury as well as obvious tissue damage
- Low voltage (household) causes minimal cutaneous damage plus pain and neurologic sequelae
- Lightning may cause cardiac arrest and other injuries
- “Tip of Iceberg” entrance small, exit is blowout
Radiation
- Damage due to radiant energy such as nuclear explosions or contact with radioactive materials
- Sunburn (ultraviolet)
first degree
superficial, erythema (red), no blister, sensitive, spontaneous healing (epidermis)
Second Degree
superficial partial thickness or deep partial thickness, erythema, blister, painful, wet, edema, re-epithelializes in 14-20 days (at the dermal layer)
o Can go deeper
Third Degree
Full thickness, white brown/charred, leather appearance, NO blisters, insensate, affected areas depressed, produces granulation tissue, will need grafting. Can heal in months/ years but with increased chance of infection (in the fat or the muscle)- not in pain
Fourth Degree
Involvement of muscle, tendon, bone and fascia or exposure of deeper structures
o Will often require local or distant tissue flaps for reconstruction – skin grafts must have a good bed for survival
o Often requires amputation of involved extremity or digit
Meshed Graft
stretched- it’s very nice and covers a larger part- it leaves a pattern- leaves a waffle pattern
o Can tear easier and it is easier to use
Full Thickness
full includes
o The debridement takes a lot of subcutaneous tissue and blood flow to it (has to be in the general vicinity) - have to replace this- not just skin
what to do if it’s a chemical burn
- How to neutralize it and what happened
Post-OP
o Full examination/evaluation
Pay close attention to skin, incisions, skin mobility, muscle guarding
o Take limb measurements
o Discuss activity modifications that may need to be made
o Education on plan/ therapy progression
Lymphedema
Signs/symptoms infection
Complete Decongestive Therapy (CDT)
o Manual Lymphatic Drainage (MLD)
o Compression Bandaging (multi-layer, short-stretch)
o Exercise
o Skin Care
o Self Care & Risk Reduction / Education
MLD
o Clear proximal regions and nodes
o Move segmentally
o Always stretch from distal to proximal
Compression Bandaging
o Improves efficiency muscle pump
o Prevents re-accumulation of evacuated fluid
o Facilitates softening of fibrotic tissue
o *May also need patient to acquire compression for groin, abdomen, chest
o Start distal
o Layered with more compression distally creating a graduated pressure in the limb
o Increase bandage widths as needed for larger limb circumferences
o Patient and/or caregiver should learn bandaging as soon as possible
Remedial Exercise
o Part of treatment for lymphedema when limb reduction is goal
o WITH COMPRESSION
Remedial exercise includes:
Diaphragmatic breathing
Active, repetitive, non-resistive motion; distal to proximal (ROM/flexibility)
• Ball squeeze, elbow flex/ext, shoulder flex, cervical flex/ext, scap retraction
• Ankle pump, knee flex/ext, hip flex, hip abd/add
Remedial exercise— with compression
o WITH COMPRESSION If arm, include hand compression Affects deep lymphatics o Pay attention to feelings of heaviness, increased swelling o Avoid extreme temperatures o Allow adequate rest between sessions
Resistance training is beneficial
o Be cautious
o Start slow, with low weights, low repetitions
o Gradual progression
o Limit based on patient / patient’s symptoms
Aerobic Training is beneficial
– increases circulation and immune response
o Be cautious
o Start slow
o Gradual progression
Skin Care-
o Low ph moisturizer (Eucerin) o Keep clean o Clean cuts/tissue injuries and cover with an antibiotic ointment o Careful nail cutting o Use electric razor o Avoid sunburns, burns, bug bites o Wear gloves with outdoor work
Self-care
o Self-manual lymphatic drainage o Self-bandaging o Donning and doffing compression garments o Exercises o Skin/nail care
No Prosthesis
o Option should be patient driven:
NOT because of non-coverage
NOT because of lack of access
Reasons for no prosthesis:
Limited perceived functional benefit
Reduced sensory input
Comfort
Hot &/or heavy
Referral to OT: No prosthesis:
One-handed techniques
Posture and ergonomics
o Yearly follow-up to ensure functional requirements are met
Oppositional Prosthetics benefits
Provides aesthetic appearance Light weight & simple Functions • Opposition • Holding objects • Restore body image Proprioceptive feedback
Limitations Oppositional prosthesis
No active prehension
High cost for custom
Durability
Patient can have unreal expectations for cosmesis
Body-Powered Prosthesis
o A.k.a. ‘cable driven’ o Relies upon gross body movements captured through a harness o Benefits Moderate cost and weight Durable Environmentally resistant Proprioception through harness system
Limitations of Body-powered prosthesis
Grip strength or pinch force
Restrictive & uncomfortable harness
Requires muscle power & excursion
Poor static & dynamic cosmesis
Hybrid Prosthesis
o A single prosthesis in which two or more technologies are combined
o Less weight than fully powered system
o More grip strength than a body powered system
o Elbow: Body-Powered
o Hand: Externally Powered
Benefits of Hybrid
Simultaneous control of the elbow and terminal device
Reduced weight compared to all electric
Limitations of Hybrid Prosthesis
Less pinch with cable controlled TD
Difficult to lift battery powered TD
Activity Specfic
o A.k.a. ‘Adaptive’ or ‘recreational’ prosthesis
o Prosthesis is designed for a specific activity
o An adaptation to an existing prosthesis
o Limitations exist in all prosthetic approaches
o Multiple devices may be needed to address functional deficits
Multi-articulate hand/durable electric hook
Body powered device/externally powered device
Terminal Prosthetic
A component of an upper extremity prosthesis that substitutes for the functions of the hand. There are many types of terminal devices, some of which are designed for use with specific tools and implements. Thesedevices have two primary actions: voluntary opening and voluntary closing.
- Non-Thermal or Mechanical Ultrasound: Facilitates wound healing
o through destabilization of cellular membrane through ion diffusion and subsequent increase in phagocytic activity and eventually enhanced protein synthesis
o can be used to decrease inflammation in both acute and chronic inflammatory conditions with low intensity
- Continuous ultrasound: used for thermal (heating) effect
o used for 5-8 or more minutes
o can be used for healing scar tissue
o heating joint capsules, ligaments, and tendons to loosen adhesions
o increases ROM, decreases muscle spasms, decrease edema
o increase tissue length and facilitate function
o therapeutic interventions should be initiated during or immediately following application of thermal ultrasound
Ultrasound
- 3 mhz- 3.3 never want to go over .9
- Deep above 1.0
- Understand target tissue depth
- Size of Area
- -Treatment time
- -3-5 mins per 2-3 ERA of sound head
- ERA= Effective Radiating Area
- 1 cm sound head can treat 2cm to 3 cm in 5 minutes.
- 5 cm sound head can treat 10 to 15 cm (4 to 5 inches) in 3-5 minutes.
thermal
continuous
Non-thermal
Pulsed (usually 20%)
Healing
-Low intensity (.3-.5 w/cm2) pulsed at 20%
What is an FCE
- Functional Capacity Evaluation (FCE) is an objective and comprehensive assessment of an individual’s physical and functional abilities.
Why should we perform an FCE?
Determine if an individual can do their job safely for 8 hours a day
Determine an individuals effort - or lack of
Provide objective documentation for a physician’s restrictions
Provide objective documentation of abilities for vocational rehabilitation or impairment/disability determination
Determine need for further rehabilitation (ie progression to work conditioning)
Functional activities are terminated and these are correlated with objective physiologic signs to include
Change in body mechanics
Accessory muscle recruitment, substitution patterns
Fatigue pattern, tremoring, shaking
Increased heart rate and blood pressure
Research shows a direct relationship between size of active muscle mass and the magnitude of HR increases. (Seals et al)
What is Wadell’s testing?
- A non-organic sign presented is a positive finding
- One non-organic sign in isolation may be present with some organic conditions and should be discounted
- Three or more non-organic signs is the criterion for a Positive Waddell’s Non-Organic Signs Test
- A positive non-organic sign should alert the clinician to the need for more comprehensive testing
- Superficial Tenderness
o Tender to light touch over a wide area of lumbar skin
Non-anatomic Tenderness
o Deep tenderness is felt over a wide area, is not localized to one structure, and often extends to the thoracic spine, sacrum or pelvis
Axial Loading
o Vertical pressure (1-2 lbs) over the skull while the patient is standing
o reproduces low back pain
Rotation
o Back pain is reported when the shoulders and pelvis are passively rotated in the same plane.
o In the presence of root irritation, leg pain may be a normal response
Weakness
formal strength testing reveals a partial cogwheel effect of “giving way”
Sensory
o Sensory testing reveals a diminished sensation in a stocking rather than a dermatomal distribution. Use caution when testing patients with a spinal stenosis of s/p root multiple spinal surgeries. Multiple nerve root involvement can mimic a regional disturbance.
Over-Reaction
o Over-reaction may take the form of disproportionate verbalization, facial expression, muscle tension, tremor, collapsing, or sweating
- Use caution against observer bias
- Recognize that there are considerable cultural variations
What does ORIF stand for?
- Open Reduction Internal Fixation
What does TFCC stand for?
- Triangular fibrocartilage-The disc. Like a meniscus in the knee
- Triangular fibrocartilage complex-The ligamentous borders, ECU
- and its sheath as well as the disc
Symptoms: - supination and pronation
What is ulnar abutment
- Ulnar sided wrist pain
- Pain with supination (ulna migrates distally with supination. If a positive variance exists then more pressure on TFCC and carpals)
- Pain with weight beating and power grip secondary to change in load
- Normally a 22 degree incline between ulna and radius. Weight is distributed approximately 80% radius and 20% ulna.
What is skiers thumb and how do we treat it? What is injured?
- Ulnar Collateral Ligament Injury:
- Conservative Treatment:
o Activity Modification
o Splint wear- 6 to 8 weeks
o NSAIDs
o Modalities as needed - Surgical Intervention:
o Repair ligament with pin or screw
o Thumb spica cast
o Thermoplastic splint
o 6 to 8 weeks immobilization
Scaphoid Fractures facts
- fractures are the second most common wrist injury & most commonly fractured carpal bone.
- 60-80% of carpal fractures involve this bone.
- Forearm & thumb will have a thumb spica cast with IP free for 6 to 8 weeks.
- Wrist immobilization with slight palmar flexion and radial deviation.
- Splinting after cast removal is common.
- Feels like a sprain.
- Unlike the forearm, hand, and finger bones, fractures of the scaphoid rarely show any obvious deformity.
- Diagnosis delayed for weeks, months or even years
- The fracture may occasionally be invisible on the first x-ray, only to show up on an x-ray taken weeks or months later when bone re-absorption at the fracture site occurs
Symptoms of scaphoid fractures
- Common presentation is pain in snuffbox
- Limited ROM due to pain (extension /RD)
- Decreased grip strength
- Painful grip and pinch
Healing time for scaphoid
o Expected time to union for acute fractures is 6-24 weeks:
o (1) Distal third = 6-8 weeks
o (2) Middle third = 8-12 weeks
o (3) Proximal third = 12-24 weeks
– Proximal Pole fractures don’t heal well secondary to retrograde blood flow. These fractures must undergo ORIF of either screw or pinning and might require a bone graft.
- Therapy for Scaphoid Fx
o A cast or splint is worn during fracture healing (6 to 8 weeks unless ORIF performed then they can move sooner)
o Encourage movement of digits & proximal joints, not
o thumb
o Avoid heavy lifting, gripping, contact sports, & activities such as climbing ladders
o Initially in therapy the goal is to control the pain &
o edema
Complications of scaphoid fractures
o CTS o Radial sensory n. o Edema o Pin infections o Complex Regional Pain Syndrome (CRPS) o Ligament injures
Stable fractured clavicle
o Arm Support
o Medication
o Physical Therapy
Unstable fractured clavicle
o ORIF- plates and screws
Pins or Screws
Pain management
Rehab
Stable fractures of the radial head and humeral head protocol…when can they perform AROM.
Non-displaced Radial Head: 3 weeks AROM
DISI
Lunate is also known as an intercalated segment
Scapho lunate tears result in a dorsal intercalated segment instability or DISI because lunate is hanging out with the triquetrium
VISI
Volar intercalated segment instability
Lunate hangs with the scaphoid in flexion
Comminuted Fracture-
involves shattering of bone into pieces; usually takes the longest to heal.
Compound
bone pierces through skin
Incomplete
-Greenstick Fracture : characterized by a small crack and is most commonly found in children
- Hairline Fracture
Complete
Simple fracture: Transverse, oblique, spiral, impacted
Fractures can be angulated, displaced, distracted and pathological.
Growth plate fractures through the epiphyseal plate
What is the CV cutoff for grip testing?
- (standard is 15%)
- The coefficient of variation represents the ratio of the standard deviation to the mean and is a useful statistic for comparing the degree of variation from one data series to another.
What does PDC stand for?
- Physical Demand Characteristics
o Physical level of performance is based on the 5 physical demand ratings established by the US Department of Labor published in the Dictionary of Occupational Titles
o We fall into the medium
Precautions of ultrasound
o Altered thermal sensibility o Area of acute inflammation o Fracture (non-healed) o Growth plate o Breast Implants
Contraindications for heat
o Diminished sensation (Use caution). Absent sensation never use.
o Very young or very old.
o Nerve laceration with an insensate hand.
o Impaired circulation (Use caution with diabetics)
o Vascular instability (skin graft, replant)
o Raynaud’s Disease- Vascular disease. Heat hardens arteries and causes damage.
o Acute inflammation
o Impaired cognition/mentation
o Open wounds
o Over a malignant site
o Over rashes or skin conditions
o Bleeding tendencies/hemophelia
o Rheumatoid arthritis
Precautions for heat
o Deep vein thrombosis (only under physicians order) o Infection (under physicians order)
Cold therapy precautions
o Cognitively impaired o Over an open wound unless using a whirlpool or water flushing modality. o Hypertension o Poor sensation o The very young or the very old
Precautions for electrotherapy
o Avoid thoracic region as it may interfere with heart activity
o Patients with demand-type pacemakers
o Areas of phrenic nerve or bladder stimulators
o Avoid carotid sinus
o Caution with hyper and hypotension patients
o Peripheral vascular disease and clotting disorders
o Cancer , infection, tuberculosis
o Pregnant women or over a pregnant uterus in first trimester
o Obese patients require too high of level of intensity secondary to impedance.
o Cognitive deficits
o Diabetic neuropathy, MS, peripheral neuropathy
o Muscular dystrophy
o Skin conditions, rash, eczema, acne
o When AROM is contraindicated
o Near superficial metal pins, plates or hardware.
NMES
o Muscle reeducation and prevention of disuse atrophy
o Decreasing muscle spasm
o Decreasing edema
Interferential current
o Used for Pain control
o Intersection of 2 sine wave frequencies
FES
electrical stimulation’ (ES), is a modality used primarily for strengthening muscles, without the purpose of integrating a functional task
Iontophoresis
o The process of introducing a topically applied medication into the tissue through an electrical current
o Dosage = miliamps x minutes
o Indicated for inflammatory conditions, CTS, epicondylitis, tendinitis/tenosynovitis, etc…
o Dexamethasone is most common medication
High Voltage
o Used for pain control, edema reduction and wound healing
o Interupted monophasic waveform
o Voltage greater than 100 volts
o Pulse duration: 2-50 per pulse
o Frequency varied by clinician
o Intensity noxious, usually below motor threshold 200-2500 mA
o Polarity control by clinician (-) vasoconstriction (+) vasodilation
o Wound care (-) if microorganisms present
o 50-120 pps for acute pain, 5 -15 for chronic pain
TENS
o Sensory Level stimulation “conventional level” High Rate
o Stimulation at or above sensory threshold and below motor threshold
o Frequency 50-150 pps
o Pulsed duration: 50-150sec (comfort)
o Intensity 20-30 mA
o Duration 20-30 mins
o At or proximal to site of pain
What is MLD
Increases the movement of lymph/interstitial fluid, including proteins
Improves lymph transport capacity, lymph vessel contractility
Stretching of the skin affects the superficial lymph vessels
Pressure phase promotes fluid movement in a desired direction
Relaxation phase causes a vacuum due to the distention of the tissue and leads to refilling of the lymph vessels
Slow technique, 5-7 repetitions per area
Gentle technique
Do not rub or create redness
*Side effects – increased urine output
Know what secondary complications can occur following a mastectomy (lymphedema etc)
Infection, Lymphedema, axillary web syndrome, and radiation fibrosis
Axillary web
o Thickened fascial cord(s) running just under the skin, visible or palpable when the upper extremity is in a flexed and abducted end range position
o 2. Subjective report from the patient includes the experience of “pulling” through area of cording and beyond.
o 3. Limited range of motion in area of cording
o 4. Reports of discomfort or pain in area of cording
Radiation Fibrosis
o Myofascial release techniques/ soft tissue mobilizations
o Manual lymphatic drainage
o Gentle stretching
o Neural mobilization of the upper extremity
Rule of 9’s
- – 1% = patient’s palm, doesn’t differentiate children from adults
Special Type of Burn- TENS or Steven Johnson’s Syndrome
- – toxic epidermal necrolysis, mimics partial thickness thermal injury, clinical symptoms are fever, systemic toxicity and cutaneous lesions, result of allergic reaction to a drug
