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7

Burns and Wounds

Michele P. West, Kimberly Knowlton,

and Marie Jarrell-Gracious

Introduction

Treating a patient with a major burn injury or other skin wound is

often a specialized area of physical therapy.' Physical therapists

should, however, have a basic understanding of normal and abnormal

skin integrity, including the etiology of skin breakdown and the factors that influence wound healing. The main objectives of this chapter are therefore to provide a fundamental review of the following:

1. The structure and function of the skin (integument)

2.

The evaluation and physiologic sequelae of burn injury,

including medical-surgical management and physical therapy

intervention

"'For the purpose of this chapter, an alteration in skin integrity secondary to a

burn injury is referred ro as a burn. Alteration in skin integrity from any other

etiology is referred to as a wound.

435

436 AClITE CARE HANDBOOK FOR PIIYSICAL TIIERAPISTS

3.

The etiology of different types of wounds and the process

of wound healing

4.

The evaluation and management of wounds, including

physical therapy intervention

Structure and function: Normal Integument

Stnlcture

The integumentary system consists of the skin and its appendages

(hair and hair shafts, nails, and sebaceous and sweat glands),

which are located throughout the skin, as pictured in Figure 7-1.

Fr" nervI

endln91

TactlM! corpuscle

pipill.

DERMIS

S41bIceoullIl.nd

Blood_I

SubcutlllKlln

pepilll

H.ir follicle

H.ir pipill.

t ,land

SUBCUTANEOUS

CONNECTiVe

TISSUE

p.cini.n corpuscle

Nerve bundle

Figure 7-1. Three-dimensional representation of the skin and subcutaneous connective tissue layer showing the a"allgemellt of hair, glands, and blood vessels.

(With permission from N Palastallga, D Field, R Soames, e/ al. Anatomy and

Human Movement {2nd ed!. Oxford. UK: Butterworth-Heineman", 1989;49.}

BURNS AND WOUNDS 437

Skin is 0.5-4.0 mm thick and is composed of twO major layers: the

epidermis and the dermis. These layers are supported by subcutaneous tissue and fat that connect the skin to muscle and bone. The thin, avascular epidermis is composed mainly of cells containing

keratin. The epidermal cells are in different stages of growth and

degeneration. The thick, highly vascularized dermis is composed

mainly of connective tissue. Table 7- 1 lists the major contents of

each skin layer.

The skin has a number of clinically significant variations: ( 1) Men

have thicker skin than women; (2) rhe young and elderly have thinner

skin than adults'; and (3) the skin on various parts of the body varies

in thickness, number of appendages, and blood flow.' These variations affect the severity of a burn injury or skin breakdown, as well as the process of tissue healing.

Function

The incegument has seven major functionsJ:

I.

Temperature regulation. Body temperature is regula red by