1. RCS 6080 Medical and Psychosocial Aspects of Rehabilitation Counseling
Wound Healing, Burn Injuries & Plastic Surgery

2. Wounds
Any breach in the surface of the body or any tissue disruption produced by the application of energy
Usually physical injury
Abrasion, degloving injury
Contusion, crush injury
Incision, laceration

3. Skin content refresher

4. Wound Healing As wound heals: Proper wound healing:
Fluid and cells drain from damaged tissue
Exudate may be:
Clear
Bloody
Pus-containing
Proper wound healing:
Cleanliness and care of lesion
Proper circulation
Good general health and nutrition

5. Phases of healing Inflammatory Reparative Consolodative
Bleeding/clotting
Migration of WBCs
Cell swelling
Reparative
Laying down of collagen + migration of epith. cells
New capillary loops
Proliferation of fibroblastsstrands of collagen
Consolodative
reorientation +contraction of collagen
collagen synthesisdegradation
 vascularity

6. Complications Hypertrophic scar = continued production of collagen
Keloid = ….with extension into surrounding tissues
Scar contracture
The hypertrophic scar is defined as a widened or unsightly scar that does not extend beyond the original boundaries of the wound. Unlike keloids, the hypertrophic scar reaches a certain size and subsequently stabilizes or regresses.
Keloid scars are defined as an abnormal scar that grows beyond the boundary of the original site of a skin injury. It is a raised and ill defined growth of skin in the area of damaged skin. Although anyone can form a keloid scar some ethnic groups are at more risk of developing them. You are 16% more susceptible if you are African-American or Hispanic. Keloid scars are seen 15 times more in highly pigmented ethnic groups rather than Caucasians.

7. Plastic surgery Scar Revision Laser resurfacing/dermabrasion Z-plasty
Skin-grafting/flap surgery
Tissue expansion

8. Burn Injuries Statistics
Annually, there are approximately 1.25 million people in the US who sustain burn injuries
Of these, 5,500 do not survive and 51,000 require hospitalization
Persons whose burn injuries require hospitalization have about a 50% chance of sustaining temporary or permanent disability
The most common part of the body involved in burn injury is an upper extremity, followed by the head and neck

9. Effects
Burn injury causes destruction of tissue, usually the skin, from exposure to thermal extremes (either hot or cold), electricity, chemicals, and/or radiation
The mucosa of the upper GI system (mouth, esophagus, stomach) can be burned with ingestion of chemicals
The respiratory system can be damaged if hot gases, smoke, or toxic chemical fumes are inhaled
Fat, muscle, bone, and peripheral nerves can be affected in electrical injuries or prolonged thermal or chemical exposure
Skin damage can result in altered ability to sense pain, touch, and temperature

10. Burn Classification - Cause
The primary cause of burn injury is exposure to temperature extremes
Heat injuries are more frequent than cold injuries
Cold injuries almost exclusively result from frostbite
Electrical and chemical injuries constitute 5-10% of burn injuries and are largely the result of occupational accidents

11. Burn Classification - Depth
Old terminology
1st degree: only the epidermis
2nd degree: epidermis and dermis, excluding all the dermal appendages
3rd degree: epidermis and all of the dermis
4th degree: epidermis, dermis, and subcutaneous tissues (fat, muscle, bone, and peripheral nerves)
New terminology
Superficial: only the epidermis
Superficial partial thickness: epidermis and dermis, excluding all the dermal appendages
Deep partial thickness: epidermis and most of the dermis
Full thickness: epidermis and all of the dermis
Superficial burns heal within 2 weeks
Full-thickness & deep partial-thickness burns require formal excision and grafting

12. Burn Classification - Depth

13. Burn Classification - Extent
Burn injuries are also classified in terms of the percentage of the skin surface injured (TBSA)
A relatively simple, but not totally accurate, method for determining the extent of injury is the rule of 9s
The ABA classification system describes burn injuries as mild, moderate, or major
head and neck total for front and back: 9%
each upper limb total for front and back: 9%
thorax and abdomen front: 18%
thorax and abdomen back: 18%
perineum: 1%
each lower limb total for front and back: 18%

14. Burn Classification – Extent Lund & Browder
Lund and Browder
More accurate
Divides body into small areas
Estimates proportion each area contributes
Takes more time and effort to calculate than Rule of Nines method

15. Burn Treatment Respiratory care Administration of fluids
Wound care (debridement)
Pain control
Plastic surgery (eg: skin grafts)
Monitoring for complications
Infections
Cardiovascular
Respiratory
Massage & Physical therapy
massage video
Posttraumatic stress

16. Pathophysiology of Burn Injury
Pathophysiology refers to the complex chain of mechanisms that occur in the skin (local effects) and in other organ systems (systemic effects) when a burn injury occurs, as well as what happens as the skin regenerates and heals
Local Effects
Systematic Effects
Skin Regeneration and Scarring
Electrical Burns

17. Burn Scars - Keloid

18. Burn Scars - Hypertrophic

19. Burn Scars - Contracture

20. Burn Scars - Contracture

21. Burn Scars - Nonraised

22. Skin Graft Scars

23. Functional Limitations
Acute Limitations
Patients may experience delirium that precludes their participation in treatment
Edema, pain, bulky dressings, and immobilizing splints impair the person's ability to perform usual daily activities
Sleep is frequently disrupted
Anxiety and fear can be present
Postdischarge Limitations
The most frequent functional limitations involve scarring and joint contracture
Other functional sequelae may result in permanent impairment

24. Rehabilitation Burn Treatment
Postdischarge
Wound care continues
If there is a risk of hypertrophic scarring, or it has already started, continuous pressure applied to the area will prevent its progress
Garments need to be worn 20 hours per day for up to 1 year - uncomfortable, hot, and unattractive
Contracture control continues through PT and/or OT
Reconditioning and strengthening exercises begin
Counseling is a possibility to work on emotional difficulties that have resulted from the burn injury
Reconstructive surgery may be needed if the functional or cosmetic limitations are not responsive to rehabilitation treatment

25. Vocational Limitations
It should be emphasized that many of the functional limitations that have already been discussed are not overtly apparent
If they are not recognized as valid, the RC could very easily conclude that a person is malingering, whining, or unmotivated
Seriousness, etiology, and site of the burn injury can significantly affect return-to-work and how long it takes
All of the studies cited in the text suggest that size, depth, and location are factors that influence time to return to work

26. Additional Resources and Information from the Web
Organizations
American Burn Association (
Burn Survivors Online (
Phoenix Society for Burn Survivors, Inc. (
JAN’s Webpage (

27. Additional Resources and Information from the Web
Burn Injury Rehabilitation Model Systems funded by NIDRR
UW/BIRMS University of Washington / Harborview Medical Center (
UT/SWMC University of Texas / Southwest Medical Center (
SBI-G Shriners Hospital for Children/ Burn Institute (
JH/BM Johns Hopkins University/Bayview Medical Center (

28. Additional Resources and Information from the Web
Related Articles from Burn Survivors Online
The Impact of Reconstructive Surgery (
Child burns survivors report good quality of life (
Degrees of burns (