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BURN\ AND WOUNDS

467

• The joints at risk for contracture formation need to be properly

positioned (Table 7-10). The positioning needs to be consistently

carried out by all caregivers and documented in the patient care

plan. Proper positioning will decrease edema and prevent contracture formation to facilitate the best recovery.

• The rherapist should be creative in treating rhe patient with a

burn. Traditional exercise works well; however, incorporating recreational acriviries and other modalities into the plan of care can ofren increase functional gains and compliance with less pain.

• The plan of care must be comprehensive and address all areas

with burns. For example, burns of the face, neck, and trunk

require intervention specifically directed to these areas.

• The therapist should attend bedside rounds with the burn team

to be Involved in multidisciplinary planning and to inform the

team of therapy progression.

Table 7-10. Preferred 11osltlOm. for P:mcnts with Burn Injury

Area of Bod)

I)osition

Neck

ExtenSion, no rotation

Shoulder

Abduction (90 degrees)

External rotation

Horizontal flexion ( 10 degrees)

Elbow and forearm

Extension With supll13tion

\Vrist

Neutral or slight extension

Hand

Functional position (dorsal burn)

Finger and thumb extension (palmar burn)

Trunk

Straight postural alignment

�hp

Neutral extension/flexion

Neutral rotation

Slight abduction

Knee

Extension

Ankle

Neutral or slight dorsiflexion

No IIlversion

Neutral roe extcnsion/flexion

Sourcc: With permission from RS Ward. Splinting. Orthotics. :lOd Prosthetics In the

Management of Burns. In M�l Lusardi, CC Nielson (eds), Orthotics and Prosthetics in

Rehahllitatlon. Boston: BUiterworth-Heinemann. 2000;315.

468 AClITE CARE HANDBOOK FOR I'HYSICAL TIIERAI'ISTS

Pathophysiology of Wounds

The different types of wounds, their etiologies, and the facrors that

contribute ro or delay wound healing are discussed in the following

sections.

Types of Wounds

Trauma Wounds

A trauma wound is an injury caused by an external force, such as a

laceration from broken glass, a cut from a knife, or penetration from

a buller.

Surgical Wounds

A surgical wound is the residual skin defect after a surgical incision.

For individuals who do not have problems healing, these wounds are

sutured or stapled, and they heal without special intervention. As the

benefits of moist wound healing become more widely accepted, gels

and ointments are now more frequently applied to surgical wounds.

W hen complications, such as infection, arterial insufficiency, diabetes,

or venous insufficiency, are present, surgical wound healing can be

delayed and tequire additional care.

Arterial Insufficiency Wounds

A wound resulting from arterial insufficiency occurs secondary to

ischemia of the tissue, frequenrly caused by atherosclerosis, which can

cause irreversible damage. Arterial insufficiency wounds, described in

Table 7-11, occur most commonly in the distal lower leg because of a

lack of collateral circulation ro this area. Clinically, arterial ulcers frequently occur in the pretibial areas and the dorsum of the toes and feet, but they may be present proximally if the ulcers were initially

caused by trauma.31-JJ They show minimal signs of healing and are

often gangrenous.

Venous Insufficiency Wounds

A wound resulting from venous insufficiency is caused by the

improper functioning of the venous system that leads to poor nutrition to the tissues. This lack of nutrition causes tissue damage, and ultimately tissue death, resulting in ulceration. The exact mechanism

by which this occurs has not been established, although some theories

do exist. One theory is that venous hypertension is transmitted ro the