Page Twelve P H Y S I O T H E R A P Y December, 1957.

MANAGEMENT OF A BURNT PATIENT
by Dennis W alker, F.R.C.S., Plastic Surgeon, Johannesburg General Hospital. 

T rea tm en t Notes by M a rjo rie H um phrey, B.Sc. (Phys.)

Th e r e  is n o  s u c h  th in g  a s “ a  tr e a t m e n t  f o r 'b u r n s ” . D a m a g e  b y  h e a t  to  t h e  la rg e s t o r g a n  o f  t h e  b o d y , t h e  s k in , is th e  
s t a r t  o f  a  se rie s  o f  illn e sse s w h o s e , d u r a t i o n , s e v e rity  a n d  
o u t c o m e  a r e  f re q u e n tly  in  d o u b t  a n d  d e m a n d  c o n s id e ra b le  
ju d g m e n t, w ith  l a b o r a t o r y  h e lp , f o r  th e ir  tr e a tm e n t.

T h e r e  w a s a  tim e  w h e n  d e s c rip tio n s  o f  b u m  d re ss in g s  w e re  
d if fe r e n t in a lm o s t e v e ry  te x t b o o k  o n e  c o n s u lte d  a n d  n e w  
a p p lic a tio n s  a n d  d re s s in g  r o u tin e s  a p p e a r e d  in M e d ic a l 
J o u r n a l s  p r a c tic a lly  e v e ry  m o n t h . T h is  n o  lo n g e r  h o ld s ; th e  
m o s t ra d ic a l c h a n g e  in  o u r  a p p r o a c h  t o  t h e  b u r n t p a t i e n t  
m a y  b e  s u m m a r is e d  in  t h e  r e a lis a tio n  t h a t  a  se v e re  b u r n  is a  
p r o b le m  in  a lte r e d  b lo o d  c h e m is tr y . T h e  p a tie n t d o e s  n o t 
u s u a lly  d ie  b e c a u s e  o f  w h a t  is d o n e  to  t h e  b u r n t a r e a  b u t 
f re q u e n tly  b e c a u s e  c h a n g e s  a r e  ig n o re d  in  t h e  p a t i e n t  a s a 
w h o le . I f  th e s e  c h a n g e s  c a n  b e  s te e re d  b a c k  to w a r d s  a  n o r ­
m a l b io -c h e m ic a l p ic tu r e  c h a n c e s  o f  s u rv iv a l a r e  im m e a s ­
u r a b ly  im p ro v e d .

O n e  o f  t h e  g r e a te s t p itfa lls  o f  m o d e r n  M e d ic in e  is t o  tr e a t  
t h e  d ise a s e  a n d  n o t th e  p a t i e n t — w e  c a n  a v o id  it, in se v e rly  
b u r n t  p a tie n ts , b y  s tu d y in g  s o m e  c o m p o n a n t s  o f  t h e  se rie s  
o f  illn e sse s w h ic h  c h a r a c t e r i s e  t h e  w e e k s , a n d  e v e n , m o n th s  
w h ic h  fo llo w  t h e  tr a g ic  few  m o m e n ts  w h ic h  tu r n  a n  a c tiv e  
c itiz e n  in to  a  b u r n t  p a tie n t.

B u r n s  a r e  c a u s e d , a s a  r u le , b y  h e a t, b u t  t h e  s a m e  b a s ic  
c h a n g e s  m a y  b e  p r o d u c e d  b y  se v e re  c o ld . S c a ld s, u su a lly  
d e s c rib e d  a s b e in g  c a u s e d  b y  m o is t h e a t, d o  n o t  d iffe r 
e s s e n tia lly  f ro m  t h e  d a m a g e  b y  d r y  h e a t.
What makes some burns more dangerous than others?

T h e r e  a r e  se v e ra l a n s w e rs  t o  th is  q u e s t io n : —
1. T h e  A rea  o f  t h e  b u r n  is t h e  m o s t i m p o r t a n t  s in g le  f a c to r .
2. D epth is u su a lly  a  s e c o n d a r y  c o n s id e r a tio n . T h is  m a y  b e  

s h o w n  b y  t h e  e x a m p le  o f  a  r e d  h o t  w ire  o r  th in  m e ta l r o d  a t  
h ig h  t e m p e r a t u r e  w h ic h , in  a  fa c to ry  a c c id e n t, m a y  p a s s  
r ig h t th r o u g h  a  h a n d . T h e  d e p t h  o f  t h e  b u m  is g r e a t -  
in v o lv in g  a ll s tr u c t u r e s  p r e s e n t— s k in , s u b c u t a n e o u s  f a t, 
te n d o n s , b lo o d  v essels, m u s c le  a n d  p o ss ib ly  b o n e — b u t o n e  
w o u ld  n o t  e x p e c t th is  b u r n  t o  b e  f a ta l. O n  t h e  o t h e r  h a n d  
a  sm a ll b a b y  a c c id e n ta lly  d r o p p e d  in t o  a  b a th  o f  b o ilin g  
w a te r  a n d  in s ta n tly  re sc u e d  m a y  re c e iv e  a  b u r n 'w h i c h  d o e s  
n o t in v o lv e  t h e  fu ll th ic k n e s s  o f  t h e  s k in , le t a l o n e  d e e p  
s tr u c tu r e s , b u t d e a t h  f ro m  th is a c c id e n t is c o m m o n — th e  
e x te n s iv e  a r e a  is th e  k illin g  f a c to r.

3. A ge  p la y s a n  i m p o r t a n t  p a r t  w h e n  p e o p le  a t  t h e  e x tr e m e s  
o f  life  a r e  b a d ly  b u r n t — a s  w ith  m a n y  o t h e r  in ju rie s , t h e  v e ry  
y o u n g  a n d  t h e  v e ry  o ld  s u ffe r se v e rly . T h e  f o r m e r  b e c a u s e  
th e ir  s u r f a c e  a r e a  a n d  fluid b a la n c e  b e a r  o n e  a n o t h e r  a n  
e a s ily  d i s t u r b e d  r e l a tio n s h ip — r a p id ly  th r e a t e n i n g  life, a n d  
a lm o s t e q u a lly  d a n g e r o u s  if  c a re le s sly  a n d  o v e r -e n th u s ia s ti-  
c a lly  r e m e d ie d — “ d r o w n in g ”  b y  o v e r  t r e a t m e n t  w ith  i n t r a ­
v e n o u s  flu id s is n o t u n k n o w n . T h e  h e a lth y  y o u n g  a d u l t  is 
a  re silie n t, w ell d e v e lo p e d  c r e a tu r e , a s a  r u le , w ith  g o o d  
in te r n a l a r r a n g e m e n t s  f o r  re s is tin g  s h o c k  a n d  e ffe c tin g  r e ­
p a ir s . T h e  l a t t e r  g r o u p  o f  t h e  tw o  m e n tio n e d  a b o v e — th e  
v e ry  o ld — h a v e  a  h ig h  m o r ta lity  f o r  tw o  r e a s o n s : t h e  p ro c e s s 
o f  a g e in g  le s s e n s  th e ir  re silie n c e  a n d  p o o r  n u t r itio n , p o ssib ly  
c o u p le d  w ith  o t h e r  illn e ss e s p r i o r  t o  th e  b u r n , d e p re s s e s  
t h e i r  g e n e r a l h e a l t h  s till f u r t h e r . F o r  e x a m p le , a n  e ld e rly  
la d y  liv in g  in a  r o o m  a lo n e  a n d  j u s t  h a v in g  r e c o v e re d  fro m  
p n e u m o n ia , s u b s is tin g  m a in ly  o n  c u p s  o f  te a  a n d  b r e a d  a n d  
b u t t e r , a c c id e n ta lly  s e ts fire to  h e r  c lo th in g — it is n o t  s u r ­
p r is in g  t h a t  th is p a tie n t s u c c u m b s  to  a  b u r n  t h a t  a  y o u n g  
a d u lt c o u ld  e n d u r e  w ith  r e a s o n a b le  h o p e  o f  s u rv iv a l. T h e  
p re v io u s  h e a lth  o f  th e  p a tie n t is t o o  o f te n  ig n o r e d  in a s se s s in g  
a  b u r n .

4. The S ite  o f  t h e  b u r n  f r e q u e n tly  a ffe c ts t h e  se v e rity  o f  th e  
s h o c k . F o r  a  g iv e n  a r e a  b u m s  o f  t h e  fa c e , h e a d  a n d  n eck  
b r e a s ts , in  w o m e n , g e n ita lia  a n d  p e r in e u m  in b o t h  se x e s a re  
m u c h  m o r e  s h o c k in g  t h a n  b u r n s  o f  o t h e r  p a r t s  o f  t h e  b o d y . 
P o s s ib ly  t h e  p r o f u s io n  o f  se n s o ry  n e rv e  e n d in g s  in  th ese 
r e g io n s  p la y s a  p a r t.

5. The A gents (i.e . fire , w a te r , s te a m , h o t  o il, a c id s , b o ilin g  
p o r rid g e , v a r io u s  c h e m ic a ls ) m a y  b e  o f  v a r io u s  te m p e r ­
a tu r e s  a n d  r e m a in  in c o n t a c t  w ith  t h e  sk in  f o r  p e r io d s  re la te d  
to  p h y sic a l f a c to rs . F o r  e x a m p le  a  h a n d  m a y  b e  p u lle d  a w a y  
fr o m  a  j e t  o f  s te a m  f r o m  a  k e ttle  so  t h a t  t h e  b u r n in g  p ro c e s s 
s to p s  a lm o s t a t  o n c e , b o ilin g  w a te r  ta k e s  l o n g e r  to  s h a k e  o ff 
h o t  o ils a n d  a c id s  a r e  e v e n  m o r e  te n a c io u s . T h e  clin g in g  
p r o p e r t i e s  o f  t h e  b o ilin g  p o r r id g e  a r e  d r e a d e d  b y  a ll w h o  h a v e i 
tr e a t e d  b u r n s  in  n o n - E u r o p e a n  c h ild r e n . '

Management o f Burnt Patient.
F a r  b e t t e r  t h a n  t h e  u se  o f  t h e  p h r a s e  “ th e  t r e a t m e n t  o f  a 
b u r n ”  is “ t h e  m a n a g e m e n t o f  t h e  b u r n t  p a t i e n t ”  a n d  t h e  first 
s te p  in th e  c a s e  o f  a  se v e re  b u r n  is t o  c o v e r  t h e  b u r n  a r e a  
w ith  a n y th in g  t h a t  is s te rile  t h a t  w ill n o t s tic k — u su a lly  tu lle  
g r a s  in a  sin g le  la y e r  fo llo w e d  b y  th ic k  la y e rs  o f  g a u z e  a n d  
firm  c r e p e  b a n d a g e s — fro m  th e n  o n  f o r  s o m e  c o n s id e ra b le  
tim e , w e  fo rg e t th e  b u m  a n d  tr e a t t h e  p a t i e n t . ( T h e  s a m e  
p r in c ip le s  a p p ly  in  t h e  F i r s t  A id  t r e a t m e n t  o f  a  s e v e re  b u r n —  
a v o id  o ils a n d  c r e a m s , c o v e r  t h e  b u r n  w ith  a n y th in g  c le a n  
a n d  tr e a t  th e  p a tie n t.)  A  r a p id  a s s e s s m e n t d u r in g  th is  first 
d re s s in g  g iv e s o n e  s o m e  id e a  o f  t h e  e x te n t o f  t h e  b u r n  a n d  a 
less a c c u r a te  id e a  o f  t h e  d e p t h  o f  t h e  b u m . M a n y  classifi­
c a tio n s  o f  d e g r e e s  o f  b u r n in g  m a y  b e  f o u n d  in t h e  lite ra tu r e . 
S o m e  a u t h o r s  h a v e  u s e d  six  a n d  e v e n  n in e  d e g re e s . T h e  
m o d e m  a p p r o a c h  is t o  u se  a  less c o m p lic a te d  sc h e m e  re fe rr in g  
to  th r e e  o r  e v e n  tw o  d e g r e e s :—

Degree.
1. E r y th e m a — r e d n e s s — lik e  s u n b u r n
2. B lis te rs  (V e sic a tio n )
3. F u l l  th ic k n e s s  o f  s k in  a n d  d e e p e r

e.g . fa t, m u s c le , b o n e  a s  w ell.
T h e  im p o r t a n t  d e c is io n  is w h e th e r  o r  n o t t h e  s k in  h a s b e ; n  

d e s tro y e d  in  its fu ll th ic k n e s s — o n c e  th is  d e c is io n  c a n  b e  
d e fin ite ly  m a d e  o n e  c a n  b e g in  to  p la n  fo r  sk in  r e p la c e m e n t^  
(w h ic h  w ill b e  n e e d e d  in a ll fu ll th ic k n e s s  lo s s e s— e x c e p t foiV  
v e ry  sm a ll a r e a s )  o r  o n e  c a n  c o n tin u e  t r e a t m e n t  w ith  t h e '  
r e lie v in g  k n o w le d g e  t h a t  c o n tr o l o f  s h o c k  w ill a lm o s t c e r ­
ta in ly  b e  fo llo w e d  b y  fa irly  ra p id  r e c o v e ry . T h e  s n a r e  t h a t  
lie s in a ll th is is t h a t  it is im p o s s ib le  to  a s se s s a c c u r a te ly  th e  
d e p t h  o f  tis s u e  d e s tru c tio n  in a  s e v e re  b u m  d u r i n g  t h e  firs t 
o n e  o r  tw o  d a y s  a f t e r  b u r n in g ; t h e  e r y th e m a  m a y  g o  o n - t o  
b lis te rin g , t h e  b lis te r s  m a y  h a v e  u n se e n  flo o rs  c o m p o s e d  o f  
fu ll th ic k n e s s  d a m a g e . A ll a r e a s  m a y  su ffe r so  m a n y  c h a n g e s  
lo n g  a f t e r  t h e  b u r n in g  a g e n t h a s  b e e n  r e m o v e d , t h a t  sk in  
w h o s e  v ita lity  is in t h e  b a la n c e  s o o n  a f t e r  b u r n in g  m a y  d ie  
d u r in g  t h e  s u b s e q u e n t f o rty - e ig h t h o u r s  o r  r e c o v e r  a n d  live—  
n e e d in g  n o  r e p la c e m e n t. T h is s t a te  o f  a ffa irs c a n n o t  b e  a c c u ­
r a te ly  fo re to ld  in a  s e v e re  fre s h  b u r n .

A s s e s s m e n t o f  t h e  a r e a  o f  a  b u r n  c a n  u s u a lly  b e  e s tim a te d  
b y  m o r e  th a n  o n e  m e th o d , a  c la s sic a l s e t o f  fig u re s  h a s  b e e n  
w o r k e d  o u t  b y  B e r k o w :—

A s a  r o u g h  g e n e r a l g u id e , a ll b u r n s  o f  g r e a t e r  a r e a  t h a n  
1 0 %  o f  t h e  b o d y  s u r f a c e  w ill p r o b a b ly  r e q u i r e  s o m e  i n t r a ­
v e n o u s  fluid to  r e s t o r e  to  n o r m a l t h e  s u d d e n  a n d  d a n g e r o u s  
d is tu r b a n c e  o f  t h e  b o d y ’s c ir c u la tin g  v o lu m e .

In  e x te n s iv e  b u m s  th is  r e s to r a tio n  o f  a n  e q u ilib riu m  is a  
life  s a v in g  m e a s u r e — i f  t h e  p r o f o u n d  s h o c k  p r o d u c e d  is n o t

- S U P E R F I C I A L

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1957.December,

„ * I v s ta b ilis e d  w ith in  a b o u t  tw o  d a y s , th e n  t h e  p a t i e n t ’s 
S?r r f<T u su a lly  in d a n g e r . S h o u ld  th is  c ritic a l p e r io d  b e  su r- 

n te d  it d o e s  n o t  m e a n  t h a t  a ll is w e ll— d e a th  m a y  o c c u r 
T ° ' n s  t h e  firs t th r e e  w e e k s f ro m  a  n o t c o m p le te ly  e x p la in e d  

p m ia o r  fro m  o v e r w h e lm in g  in fe c tio n  in v a d in g  t h e  d e a d  
t07 L n «  s k in  a n d  f a t. E v e n  a f te r  th is  p e r io d  t h e  p r o lo n g e d  
j  n o n  t h e  p a t i e n t ’s re s is ta n c e  b y  a  c h r o n ic  in fe c tio n ,

a a n a e m ia  a n d  p r o t e i n  lo ss a s s o c ia te d  w ith  a  la r g e  ra w
o a n d  th e  f a ilu re  to  e a t a d e q u a te ly  w i t h o u t  in te n siv e  

e n e r g e t ic  n u r s in g  a id , m a y  s till b e  fa ta l.
T h e  first th r e e  m o n th s  a f t e r  b u r n in g  m a y  c o v e r a  se rie s 

f  se v e re  illn esses. O n c e  s h o c k  a n d  in fe c tio n  a r e  c o n tr o lle d  
l  m a i o r  life -s a v in g  m e a s u re  t h a t  r e m a in s  is t h e  e a rly , 
c o m p le te  c o v e rin g  o f  a ll a r e a s  o f  fu ll th ic k n e s s  sk in  lo s s by 
sk in  g ra ftin g .

GT\  c o m m o n  q u e s tio n  is “ w h e n  s h o u ld  a  b u r n  b e  g r a f t e d ? ” 
T h e  a n s w e r is “ w h e n  it is r e a d y ” — id e a lly  th is is tw o  o r  th r e e  
w epks a f te r  b u r n in g , w h e n  b y  r e p e a te d  d re s s in g  o r  b a th in g  

a c tic e  r e m o v a l o f  s lo u g h s , a ll b u r n t  tis s u e  is r e m o v e d  
a n d  th e  ra w  a r e a  is s m o o th  a n d  re d — a  c le a n  e x p a n s e  o t 
velvety g r a n u la tio n  tis s u e .

physiotherapy.
A n o th e r  c o m m o n  q u e s tio n  is “ w h e n  sh o u ld  p h y s io th e r a p y  

s t a r t 9”  O n c e  a g a in  t h a  a n s w e r  is r a t h e r  u n h e lp f u l— “ w h e n  
th e  p a t i e n t  is r e a d y  fo r  it .”  I n  p r a c tic e  th is m e a n s  a s  s o o n  
a s s h o c k  is c o n tr o lle d . H a n d s  a r e  e i th e r  lig h tly  s p lin te r e d  o r  
d ressin g s a r r a n g e d  s o  t h a t  th e y  a s s u m e  a  p o s itio n  o f  f u n c tio n . 
F o o t  d r o p  is g u a r d e d  a g a in s t. T h e  p a tie n t is e n c o u r a g e d  to  
m o v e a b o u t  in b e d  a n d  t a k e  a n  a c tic e  p a r t  in f e s d in g  a n d  
a n y  o t h e r  r e a s o n a b le  a c tiv itie s. B r e a th in g  e x e rc ise s m a y  b e 
o f  c o n s id e ra b le  i m p o rta n c e .

Id e a lly  a  p h y s io th e r a p is t s h o u ld  b e  p r e s e n t w h e n  d re ssin g s 
a r e  d o n e  o r  b a t h s  g iv e n , u s in g  th e s e  o p p o r t u n it i e s  to  try  a n d  
m a in ta in  a  fu ll r a n g e  o f  m o v e m e n t o f  a ll j o i n t s  o r  a s m a n y  as 
p o ssib le .

I t  is o f  v ita l i m p o r ta n c e  to  t r e a t  th e  p a t i e n t  a n d  n o t t h e  
d ise a se  M o r a l e  is o f te n  lo w , c o n s t a n t  o p tim is m  is im p o r t a n t  
— s tre s sin g  p ro g re s s  a t  e a c h  d r e s s in g  o r  b a th  A  c o m m o m  
f a u lt t o  b e  a v o id e d  in re v ie w in g  t h e  l a te  e s ta b lis h e d  d e f o rm -  
a tie s o f  se v e re  b u m s  is t h e  d o g m a tic  c o n d e m n a t i o n  o f  th o s e  
w h o  tr e a t e d  t h e  p a tie n t, a n d  t h e  a s s e r tio n  t h a t  s k in  g r a ftin g  
a n d  “ s p lin tin g ” o r  o f te n  “ s p lin tin g ”  a lo n e  w o u ld  h a v e  
p r e v e n te d  t h e  d e f o r m ity  a n d , p r e s u m a b ly , re s u lte d  in b e tte r  
re sid u a l f u n c tio n .

I t  is i m p o r t a n t  t o  r e m in d  o u r s e lv e s  a g a in  a n d  a g a in  t h a t  
m e d ic in e  h a s  little  r o o m  f o r  “ a lw a y s ” o r  “ n e v e r ” . Som etim es, 
in  su p e rfic ia l b u r n s , p u z z lin g  a n d  s e rio u s  re s id u a l lm p a ir- 
rm e n t o f  fu n c tio n  a p p e a r s . Som etim es, in se v e re  b u r n s , 
fu n c tio n  is a s to n is h in g ly  g o o d  w h e n  little  c a r e  h a s  b e e n  
ta k e n  w ith  g r a ftin g  a n d  m a in ta in in g  f u n c tio n a l p o s itio n s  o t 
lim b s a n d  th e ir  jo in ts .

G e n e r a l truths w h ic h  f a r  m o r e  n e a r ly  fit t h e  fa c ts a r e  t h a t : —
1. F u ll th ic k n e s s  b u r n s  r e s u lt in a n  a r e a  o f  c o m p le te  d e ­
n u d a tio n  o f  s k in — p ro v e d  w h e n  slo u g h  s e p a ra te s
2. N a t u r e  h e a ls o r  a t t e m p t s  t o  h e a l su c h  a n  a r e a  b y  a  p ro c e s s  
w h ic h  r e s e m b le s  t h e  d r a w in g  t o g e th e r  o f  t h e  e d g e s o f  a  w o u n d  
r e g a rd le ss o f  f u n c tio n a l lim ita tio n s  w h ic h  m a y  b e  p r o d u c e d .
3. T h e  w a y  in  w h ic h  t h e  c o n t r a c t i o n  o f  a  ra w  a r e a  in flu e n c e s 
th e  p a r t  in  w h ic h  it lie s, d e p e n d s  on '.

(a) w h e th e r  it is o v e r  a  jo i n t  s u r f a c e — if  th is  o s s o  t h e  j o i n t  
ra n g e  b e c o m e s  lim ite d  b y  rig id  s c a r  tiss u e  fo rm a tio n . 
C h a n g e s  in  s u b c u ta n e o u s  tis s u e s , m u s c le s, te n d o n s  a n d  j o i n t  
c a p s u lr  a r e  la rg e ly  s e c o n d a r y — ra re ly  a r e  te n d o n s , m u sc le s 
a n d  t h e  j o i n t  its e lf  d a m a g e d  b y  b u r n in g .

(b ) w h e th e r  t h e  a r e a  is g r a f te d  e a r ly , so  d e fy in g  t h e  e d g e s 
to  c o m e  to g e th e r . E a rly  s k in  g r a ftin g  h a s  t h e  in e s tim a b le  
v a lu e  o f  t u r n in g  a n  o p e n  w o u n d , w ith  a ll its d a n g e r s  o f  in ­
fe c tio n , p r o t e i n  lo ss a n d  a n a e m ia ; in to  a  closed w o u n d . A  
clo se d  w o u n d  o ffe rs tim e  t o  th in k  a n d  p la n , to  g a in  m a x im u m

P H Y S I O T H E R A P Y Page Thirteen

m o v e m e n t b y  p h y s io th e r a p y , a n d  p re v e n ts  t h e  la y in g  d o w n  
o f  f u r t h e r  s c a r tiss u e .

N o  o n e  w ith  a  r e a s o n a b ly  w id e  e x p e rie n c e  o f  t r e a t m e n t  o f  
b u r n s , c la im s t h a t  g r a ftin g  e n tir e ly  p revents c o n t r a c t u r e s , 
b u t it m inim ises t h e i r  se v e rity  b e y o n d  a ll m e a s u re , s o  t h a t  
r e - e d u c a tio n  a n d  f u tu r e  r e c o n s tr u c tiv e  s u rg e ry  c a n  b e  u n d e r ­
ta k e n  e a r lie r, a n d  w ill g iv e  b e tte r  re s u lts .
Conclusion.

F in a lly , I  w o u ld  sa y  t o  a l l  p h y s io th e r a p is ts , b e w a r e  o f  t h e  
u n w a n te d  g u e s t w h o  o u ts ta y s  h is w e lc o m e — t h e  l o n g e r  y o u  
le a v e  h im  t h e  m o r e  d iffic u lt h e  is to  e lim in a te — in o t h e r  w o rd s
— war on oedema— if le f t s ta tic  it u n d e r g o e s  fib ro u s  r e p l a c e ­
m e n t, lo c k in g  s u r f a c e s  t o  t h e  d e p th s .

W e  c a n n o t  su c c e e d  in is o la tio n — t h e  p a t i e n t  n e e d s  h e lp  
fro m  a ll o f  us.

P H Y S I O T H E R A P Y  T R E A T M E N T  
T h e s e  n o te s  o n  p h y s io th e r a p e u tic  m e a s u re s  u se d  in t h e  

m a n a g e m e n t o f  a  b u r n t  p a tie n t a r e  in te n d e d  o n ly  a s  a  b r o a d  
o u tlin e  fo r  p o s s ib le  tr e a t m e n t . A s M r . W a lk e r  h a s p o in te d  
o u t, p h y s io th e r a p y  s t a r ts  “ w h e n  t h e  p a tie n t is r e a d y  f o r  i t ” 
a n d  a s s o o n  a s  s h o c k  is c o n tr o lle d .
Pre-operative Treatment.
(a ) B r e a th in g  e x e rc ise s.
(b ) A  f u ll r a n g e  o f  m o v e m e n t t o  a ll jo in ts  n o t  d ire c tly  in ­
v o lv e d  in t h e  b u r n t  a r e a , a n d  a s m u c h  a s p o s s ib le  w ith o u t 
p a in  t o  in v o lv e d  jo in ts .
(c) B a d ly  b u r n t  p a tie n ts  a r e  g iv e n  s ta tic  c o n t r a c t i o n s  to  a ll 
p a r ts  b e f o re  g r a ftin g .
(d ) W h e r e  t h e  b u m  is o v e r  t h e  j o i n t , s ta tic  c o n t r a c tio n s  t o  
t h e  m u sc le s  a r o u n d  t h e  j o i n t  s h o u ld  b e  g iv en . L e t p a in  b e  t h e  
l im itin g  f a c to r  in j o i n t  .m o v e m e n ts  in a  fre sh  b u r n .
(e) E ld e rly  p a tie n ts  s h o u ld  b e  e n c o u r a g e d  t o  s it u p  in a  c h a ir  
f o r  p a r t  o f  t h e  d a y .
(f)  C h ild r e n  w ith  se v e re  b u r n s  a r e  p r o n e  t o  b r o n c h o - p n e u -  
m o n ia . T h e r e f o r e  p o s t u r a l  d r a in a g e  is u su a lly  g iv e n  a u t o ­
m a tic a lly  t o  e v e ry  c a se . T h is  c a n  b e  d o n e  b y  e ith e r  tip p in g  
t h e  b e d  o r  e le v a tin g  t h e  c h ild  o n  p illo w s. I f  h e  is a llo w e d  to  
b lo w  b u b b le s , o r  f o r  th o s e  p h y s io th e r a p is ts  w h o  h a v e  s t r o n g  
n e rv e s ,— a  t r u m p e t  o r  w h istle , h e  w ill to le r a te  th is  p o s itio n  
f o r  a  lo n g  tim e .
Post-operative Treatment.

M o v e  e v e r y th in g  b u t  t h e  g r a fte d  a r e a  f o r  t h e  first few  d a y s , 
o r  u n til p e r m is s io n  is re c e iv e d  f ro m  t h e  s u r g e o n  t o  m o v e  t h e  
g r a fte d  a re a .
Donor Areas.

S ta tic  c o n t r a c t i o n s  t o  t h e  m u sc le s ly in g  b e n e a th  t h e  ra w  
a r e a . T h is  is v e ry  i m p o r t a n t  e s p e c ia lly  i f  t h e  g r a f t h a s  b e e n  
ta k e n  f ro m  t h e  th ig h s. A im  t o  g e t s tr a ig h t le g  ra is in g  as 
s o o n  a s p o ss ib le .
Dressings.

A  c a re le s s d re s s in g  t e c h n iq u e  c a n  a llo w  in f e c tio n  t o  c r e e p  
in to  t h e  g r a fte d  a r e a  w ith  r e s u l t a n t  n e c ro sis .

T h e  v a s c u la r  s u p p ly  t o  t h e  w o u n d  c a n  b e  s e rio u s ly  e m ­
b a r ra s s e d  b y  a  b a n d a g e  t o o  tig h tly  a p p lie d , w ith  t h e  s a m e  
r e s u lt a s  a b o v e .

W h e n  t h e  d re ss in g s a r e  re m o v e d  a ll g r a f te d  p a r t s  s h o u ld  
b e  m o v e d , e s p e c ia lly  w h e r e  t h e  g r a f t  is o v e r  a  j o i n t . R a n g e  
sh o u ld  b e  in c r e a s e d  v e ry  g r a d u a lly  t o  a v o id  d is p la c in g  o r  
d a m a g in g  t h e  g r a f t.
Baths.
(a ) Saline.

N o r m a l  sa lin e  b a th s  m a y  b e  g iv e n  a t  a n  e a r ly  s ta g e  a n d  
a r e  e s p e c ia lly  u se fu l w h e r e  b u r n in g  is e x te n s iv e . M o v e m e n ts  
a r e  c a r r ie d  o u t  in t h e  b a th , a n d  t h e  s e p a r a tio n  o f  slo u g h  
e s s e n tia l b e f o re  g r a ftin g — is h a s te n e d .
(b ) L u x .

L u x  h e lp s t o  s te ra liz e  t h e  b u r n t  a r e a  (2 s m a ll p a c k e ts  t o  a 
fu ll b a th ) .

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Page Fourteen P H Y S I O T H E R A P Y December, 1957.

I f  th e ir  is a  s m a ll h a ir  d r ie r  a v a ila b le , u s e  th is t o  d r y  t h e  
r a w  a r e a s  r a t h e r  t h a n  a  to w e l, w h ic h  m a y  c a u s e  f u r t h e r  
b le e d in g .

Splints.
T h e s e  a r e  u s u a lly  m a d e  o f  p a d d e d  K r a m e r  w ire  o r  lig h t 

P la s te r  o f  P a r is  sh e lls— th in ly  p a d d e d . I f  t h e  g r a f t is o v e r  a  
fle x o r s u r f a c e — p a r tic u la r ly  t h e  k n e e , e lb o w  a n d  w ris t jo i n t s  
a  s p lin t is w o r n  t o  m in im is e  c o n tr a c tu r e s . S p lin ts s h o u ld  b e  
w o r n  a t  n ig h t a n d  r e m o v e d  f o r  e x e rc ise s.

Grafts over the Groin.
T h e  p a tie n t is n u r s e d  in ly in g  o r  p r o n e  ly in g . H e  m a y  b e  

a llo w e d  t o  s ta n d  o r  w a lk , b u t s ittin g  s h o u ld  b e  d is c o u ra g e d . 
F o r  c h ild r e n , h o ld  t h e  le g s in  a  g o o d  p o s itio n  b y  m e a n s  o f  
to w e ls a n d  s a n d  b ag s.

Grafts over the N eck.
N u r s e d  in  ly in g  w ith  o n e  v e ry  s o ft p illo w .

G r a fts  o v e r th e  E lb o w  a n d  K n e e  ( E x te n s o r  S u rfa c e s.) - 
E n c o u r a g e  e x te n s io n  n o t fle x io n .

Grafts in Lower Leg' and Foot.
1. Q u a d r ic e p s  d r ill o n ly  f o r  f o u r  d a y s.
2. 5 th  d a y . M o v e m e n ts  t o  to e s  a n d  a n k ls s .
3. 6 th  t o  10th d a y . H a n g  t h e  le g  o v e r  t h e  s id e  o f  t h e  b e d  f o r  
only  5 m in u te s  o r  less e v e ry  h a l f  h o u r . R e m a in  w ith  t h e  
p a t i e n t  a n d  w a tc h  t h e  g r a f t c a re fu lly . I f  t h e  g r a ft g o e s  to o  
b lu e  r e p la c e  in  b e d  im m e d ia te ly . I n  g e n e r a l t h e  h a z a r d s  o f  
c y a n o s is — in d ic a tin g  a  p o o r  v e n o u s  r e t u r n  f r o m  a  f re e  g r a f t  
o r  fla p — a r e  m u c h  g r e a te r  t h a n  th o s e  o f  p o o r  a r t e r i a l  s u p p ly  
— in d ic a te d  b y  p a l l o r  o f  t h e  g r a f t  o r  fla p .
4 . 7 th  to  1 4 th  d a y . U s in g  a  c r e p e  b a n d a g e , b a n d a g e  t h e  le g  
f r o m  t h e  to e s  to  t h e  tu b e r c le  o f  t h e  tib ia  a n d  sit t h e  p a t i e n t  
o u t  in a  c h a ir  f o r  h a l f  a n  h o u r  tw ic e  d a ily .
5. 8 th  t o  2 0 th  d a y . W a lk in g . W a tc h  t h e  g r a f t. I f  it b e c o m e s  
v e ry  b lu e  r e t u r n  t h e  p a t i e n t  t o  b e d  im m e d ia te ly .

A ll tim e s  a r e  a p p r o x i m a t e  a n d  m u s t b e  m o d ifie d  b y  t h e  
ty p e  o f  g ra ft.

Grafts to Hands.
T h e s e  a r e  b a n d a g e d  in a  f u n c tio n a l p o s itio n  u n til t h e  g r a f t 

h a s  t a k e n . N o  m o v e m e n ts  a r e  g iv e n . C a r e  s h o u ld  b e  t a k e n  
to  s e e  t h a t  t h e  h a n d  is e le v a te d  a n d  m a in ta in e d  in  th is  p o s i t ­
io n  to  p r e v e n t sw e llin g . F i n g e r  tip s  m u s t b e  e x p o s e d  w h e n e v e r  
p o ss ib le .

Grafts over Concave Surfaces.
N o  m o v e m e n ts  a r e  g iv e n  a s it is t h o u g h t  t h a t  e x e rc ise s 

in c r e a s e  t h e  te n d e n c y  f o r  f ib ro u s  tis s u e  t o  c o n t r a c t  a n d  
in c r e a s e  t h e  r is k  o f  h a e r r ia to m a  b y  d is tu r b in g  p r e s s u re  
d re s s in g s  o r  m o u ld , h o ld in g  t h e  g r a f t  in  p o s itio n  a g a in s t t h e  
w a lls o f  t h e  c a v ity .

Oedema.
E x p la in  t h e  d a n g e r s  o f  o e d e m a  a n d  le a v e  t h e  p a t i e n t  to  

w o r k  it a w a y . E n c o u r a g e  a n y  a c tiv e  m o v e m e n ts  a n d  g iv e  t h e  
p a t i e n t  p la s tic in e  o r  a  s m a ll r u b b e r  b a ll t o  s q u e e z e . W h e r e  
m o v e m e n t is t o o  s m a ll t o  b e  u s e fu l, i f  t h e  lim b  is in p la s te r, 
h a n g  it u p  a n d  l e t g r a v ity  d r a i n  it a w a y .

N o  passive m ovem ents s h o u ld  b e  g iv e n  u n le s s  b y  a  d o c t o r  
u n d e r  a n  a n a e s th e tic , o r  w h e n  s p e c ia lly  o r d e r e d  a n d  t h e  g r a f t 
is “ s a fe ”  a n d  m a tu r in g .

M assage.
V e ry  little  is g a in e d  b y  m a s s a g e  in  t h e  e a r ly  s ta g e s. W h e n  

t h e  w o u n d  is c o m p le te ly  h e a le d , m a s s a g e  w ith  o liv e  o il w ill 
h e lp  t o  s o f te n  t h e  g r a fte d  a r e a , w h ic h  is o f te n  r a t h e r  d r y  o r  
sc a ly .

W a x  B aths.
V e ry  c o o l w a x  b a t h s  a r e  a ls o  h e lp fu l. T h e  d a n g e r  o f  

s e p s is  is n e g lig ib le  a n d  th e s e  c a n  b e  g iv e n  a f t e r  a b o u t  th r e e  
w e e k s .

S h o rt W ave D iatherm y.

U n s a tis f a c to r y  b e c a u s e  o f  t h e  lo c a l d iffic u lty  o f  p r e v e n tin g  
o v e r -h e a tin g , w h ic h  m a y  c a u s e  u lc e r a tio n . T h e  h e a lin g  is 
p a tc h y  a n d  m a y  c a u s e  a n  e p ith e lio m a  a f t e r  y e a r s  o f  c h r o n ic  
u lc e r a tio n .

In fra  R ed.

W h e r e  th e r e  is g ro s s  c i r c u la to r y  d is tu r b a n c e , f o r  e x a m p le  
in  a  ’’f ro z e n ”  h a n d , re fle x  d ila tio n  in  a n  in f r a  r e d  t u n n e l m a y  
b e  g iv en . T h is  m e th o d  w a s u s e d  w ith  su c c e ss d u r in g  th e  
w a r, w h e n  i m m e d ia te  s u r g e r y  w a s im p ra c tic a l, o w in g  t o  la c k  
o f  s p a c e  in  b a s e  h o s p ita ls .

Ultra Violet R ay.

H a z a r d o u s  o n  a  f r e e  g r a f t  a s  t h e r e  is a  d a n g e r  o f  p ig m e n ­
t a t i o n  a n d  so m e tim e s , u lc e r a tio n . T his is u s u a lly  a  d iffu se  
y e llo w ish  p ig m e n t w h ic h  d o e s  n o t  f a d e  a n d  s h o u l d  b e  g u a r ­
d e d  a g a in s t, e s p e c ia lly  w h e r e  t h e  g r a ft is o n  t h e  fa c e .

Y o u  w ill n o t b e  lo v e d  b y  y o u r  p a t i e n t  i f  h e  a c q u ir e s  a 
b e a u tif u l t a n  in  t h e  s u m m e r  b u t  is le f t to  fa c e  t h e  w in te r  
w ith  a  b r ig h t y e llo w  p a tc h  o n  h is fa c e !

I n  e s tim a tin g  t h e  a r e a  o f  a n  ir re g u la r ly  s h a p e d  b u r n t  ̂ 
a r e a  it is s o m e tim e s  u s e fu l to  r e m e m b e r  t h a t  t h e  p a lm  o f  th e  
h a n d  is a b o u t  1 %  o f  t h e  b o d y  su rfa c e .

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