Burns: Classification, Patient Management, and Rehabilitation

PART 1: CLASSIFICATION OF BURNS

A. Classification by Depth

ROSEN's Emergency Medicine (9th Ed.): "Full-thickness burns involve the entire dermis and often some underlying adipose tissue and result in an inelastic burn eschar that is waxy and white, gray, or black without blisters."

• Zone of Coagulation (center): Maximum damage, coagulated necrotic tissue - requires excision and grafting
• Zone of Stasis (middle): Variable ischemia - can convert deeper with infection or poor perfusion; can be saved with good resuscitation
• Zone of Hyperemia (periphery): Minimal damage, heals spontaneously - similar to superficial partial-thickness

B. Classification by Size - The Rule of Nines

• Anterior neck = approximately 1% TBSA
• Anterior chest = 9% TBSA (anterior trunk is 18%, chest alone is ~9%)
• Total estimated TBSA = ~10%

• Anterior neck burns risk airway compromise from edema/eschar
• Chest burns may restrict respiratory excursion
• These are classified as special area burns requiring special consideration

C. Classification by Cause

D. Classification by Severity (ABA Criteria)

PART 2: PATIENT MANAGEMENT

Step 1 - Primary Survey (ABCDE)

• Singed nasal hairs, eyebrows, facial burns
• Hoarseness, stridor, carbonaceous sputum
• Burns in an enclosed space

• Establish two large-bore IV lines (through or around burned tissue if necessary)
• Early fluid resuscitation
• Monitor urine output (Foley catheter)

Step 2 - Fluid Resuscitation

4 mL × body weight (kg) × % TBSA burned = total Lactated Ringer's in first 24 hours

4 × 70 × 10 = 2,800 mL of Lactated Ringer's over 24 hours

• Half (1,400 mL) in the first 8 hours from time of burn
• Remaining half (1,400 mL) over the next 16 hours

• Urine output: 30 mL/hour in adults (0.5 mL/kg/h)
• Mean arterial pressure: >60 mmHg

Step 3 - Wound Assessment and Initial Care

1. Gentle cleaning - remove debris, loose dead tissue, open blisters
2. Topical antimicrobials - the cornerstone of preventing wound infection:
   • Silver sulfadiazine 1% - broad spectrum, most widely used
   • Mafenide acetate - penetrates eschar, useful for deep burns
   • Silver-containing dressings (e.g., Mepilex Ag, Aquacel Ag) - modern alternatives with less frequent changes
3. Dressing goals (Sabiston Textbook of Surgery):
   • Protect damaged epithelium
   • Minimize bacterial/fungal colonization
   • Maintain moist wound environment
   • Reduce evaporative heat and cold stress
   • Provide comfort
   • Splint in position of function

Step 4 - Surgical Management

• Release the chest wall for adequate ventilation
• Prevent compression of the airway/vascular structures in the neck

• Superficial partial-thickness burns - heal conservatively with dressings in 1-3 weeks
• Deep partial-thickness burns - benefit from excision and split-thickness skin graft (STSG); early grafting reduces hospital stay, infection, and scarring
• Full-thickness burns - require excision and grafting (STSG or full-thickness skin graft)

• Contour and mobility requirements make the neck technically challenging to graft
• Sheet grafts (not meshed) are preferred for the face and neck to optimize cosmesis and reduce scarring
• Z-plasty or flap reconstruction may be needed for contractures if they develop later

Step 5 - Analgesia and Sedation

• Opioids (morphine, fentanyl) - for background and procedural pain
• Paracetamol + NSAIDs - adjuncts
• Ketamine - excellent for dressing changes (provides analgesia + dissociative sedation)
• Gabapentin/pregabalin - for neuropathic pain
• Patient-controlled analgesia (PCA) where applicable

Step 6 - Nutritional Support

• Preserves gut mucosal integrity, reduces bacterial translocation, and supports healing
• Caloric requirements calculated using Curreri formula (adults): (25 kcal × weight) + (40 kcal × % TBSA burned)
• High-protein diet: 1.5-2 g/kg/day
• Nasogastric feeding if oral intake is insufficient

Step 7 - Infection Prevention and Monitoring

• Topical antimicrobials (as above) - systemic prophylactic antibiotics are NOT routinely recommended
• Regular wound surveillance for signs of infection (increased exudate, erythema, fever, leucocytosis)
• Wound swabs and blood cultures if infection suspected
• Tetanus prophylaxis
• Scheduled replacement of IV lines to minimize catheter-related sepsis

PART 3: REHABILITATION

1. Neck flexion contracture (chin-to-chest deformity)
2. Chest wall restriction limiting respiratory function
3. Hypertrophic scarring
4. Psychological impact

Phase 1: Acute Phase (Day 1 to wound closure)

• The neck must be positioned in neutral to slight extension - NOT in flexion (which is the position of comfort but leads to contracture)
• Use a foam cervical collar or conformer to maintain neck extension when at rest
• Head of bed elevated 30-45° to reduce edema
• Shoulders in slight retraction to prevent pectoral contracture from chest burns

• Begin passive ROM from Day 1 - even through bandages
• Cervical ROM: flexion, extension, lateral flexion, rotation
• Shoulder ROM: flexion, abduction, external rotation (anterior chest burns pull the shoulder into adduction and internal rotation)
• Trunk extension exercises to counter chest tightening
• Progress to active-assisted ROM and then active ROM as tolerated
• Exercise should be performed before dressing changes when analgesia is at its peak

• Anterior chest burns are a unique challenge - the scar can restrict chest expansion and cause restrictive lung defect
• Deep breathing exercises, incentive spirometry
• Active cycle of breathing technique (ACBT)
• Humidified oxygen and nebulized bronchodilators if inhalation injury present
• Early mobilization - even ventilated patients can be sat out of bed with sufficient analgesia (Sabiston Textbook of Surgery)

Phase 2: Post-Grafting / Sub-Acute Phase (Wound closure to 3-6 months)

• The mainstay of hypertrophic scar prevention and treatment
• Custom-fitted compression garments providing 24-25 mmHg pressure are worn 23 hours/day for 12-24 months
• For the neck: a cervical compression collar and/or a face/neck mask (transparent facial orthosis)
• For the chest: a compression vest
• Mechanism: reduces blood flow to the scar, flattens and softens the scar tissue, and reduces pruritus
• Garments must be replaced every 2-3 months as they lose elasticity and as the patient changes shape

• Silicone gel sheets or gel applied under pressure garments
• Softens and flattens hypertrophic scars
• Used 12-24 hours/day in combination with compression garments
• Mechanism: hydration of the stratum corneum, reducing collagen synthesis in the scar

• Neck conformer/extension splint to prevent chin-to-chest contracture
• Worn at night (or 24 hours a day in resistant contractures)
• The three-poster brace or custom thermoplastic conformer holds the neck in extension, lateral flexion, and rotation
• Chest brace or trunk extension splint to prevent pectoral tightening

• Once wounds are fully closed, scar massage begins
• Firm circular massage using a neutral cream for 10-15 minutes per session, 2-3 times daily
• Softens the scar, reduces adhesions, and improves tissue mobility

• Progressive stretching of neck flexors and pectorals
• Shoulder strengthening and thoracic mobility exercises
• Resistance training as tolerated

Phase 3: Long-Term Rehabilitation (6 months onward)

• Z-plasty - gold standard for linear contractures; the interdigitating flaps by design lengthen the contracted site
• Y-V plasty - for shorter contractures
• Full-thickness skin grafts - replace more dermis, reducing recurrence of contracture compared to split-thickness grafts
• Pedicled or free flaps - for complex or recurrent contractures

• Burns of the neck and chest are visible and affect body image and social functioning
• Cognitive behavioral therapy (CBT) for adjustment disorder, depression, PTSD
• Peer support groups (burn survivor networks)
• Social reintegration programs - vocational rehabilitation, return-to-work planning
• Monitoring for post-traumatic stress disorder (PTSD)

• Hypertrophic scars are intensely itchy and this significantly impairs quality of life
• Antihistamines (cetirizine, hydroxyzine)
• Gabapentin - most effective agent for burn itch
• Topical menthol or counterirritants
• Massage and compression also reduce itch

Summary Table: Management at a Glance

• Schwartz's Principles of Surgery, 11th Ed. - Burn Depth and Resuscitation chapters
• Sabiston Textbook of Surgery, current ed. - Wound Care and Organ Failure in Burns
• ROSEN's Emergency Medicine - Classification and Diagnosis of Burns
• ACI Burn Physiotherapy & Occupational Therapy Clinical Practice Guide (Jan 2025)
• Prevention and Treatment of Burn Scar Contractures, PMC 2024

Burns: Classification & Physiotherapy Management/Rehabilitation

PART 1: CLASSIFICATION OF BURNS

A. Classification by Depth (Degrees)

ROSEN's Emergency Medicine: "Full-thickness burns involve the entire dermis and often some underlying adipose tissue and result in an inelastic burn eschar that is waxy and white, gray, or black without blisters. Full-thickness burns are insensate."

• Zone of Coagulation (center): Coagulated necrotic tissue - maximum damage, requires excision and grafting
• Zone of Stasis (middle): Variable ischemia - can deepen with infection or poor resuscitation; can be saved with good care
• Zone of Hyperemia (outer): Minimal injury, heals spontaneously

B. Classification by Extent - The Rule of Nines

• Head and neck: 9%
• Each upper limb: 9%
• Anterior trunk: 18%
• Posterior trunk: 18%
• Each lower limb: 18%
• Genitalia: 1%

• Anterior neck = ~1% TBSA
• Anterior chest = ~9% TBSA (half of the anterior trunk)
• Total TBSA burned = approximately 10%

For irregular burns, the Rule of Palm is also used: the patient's palm (including fingers) = approximately 1% TBSA.

C. Classification by Cause/Etiology

D. Classification by Severity (American Burn Association)

PART 2: PHYSIOTHERAPY MANAGEMENT

1. Maintain airway patency and respiratory function
2. Prevent neck flexion contracture and shoulder/chest tightening
3. Preserve and restore full range of motion (ROM)
4. Manage oedema
5. Manage hypertrophic scarring
6. Restore functional independence and quality of life

PHASE 1: ACUTE PHASE (Day 1 to Wound Closure)

1. Respiratory Physiotherapy

• Airway clearance techniques: Active cycle of breathing technique (ACBT), forced expiratory technique (FET/huffing), postural drainage
• Incentive spirometry: Encourages maximum inspiratory effort, recruits alveoli, prevents atelectasis
• Deep breathing exercises: Diaphragmatic and lateral costal breathing performed hourly when awake
• Positioning: Head of bed elevated 30-45° to reduce airway oedema and facilitate breathing
• Early mobilisation: Even patients on ventilatory support should be sat out of bed with adequate analgesia - this reduces respiratory complications (Sabiston Textbook of Surgery)
• If inhalation injury is present: Nebulized bronchodilators (salbutamol), nebulized heparin, and nebulized acetylcysteine are used alongside physiotherapy

2. Positioning and Oedema Management

JSM Burns and Trauma: "A neutral to slightly extended neck position achieved by removing pillows under the head during the whole wound healing process prevents the deformity of the chin and neck to either side or mandible-chest adhesion due to wound contracture and hypertrophic scarring."

• Elevation of the affected area
• Compression bandaging (elastic bandages/Tubigrip) - can begin immediately
• Active exercise to stimulate lymphatic drainage
• Avoidance of dependent positioning

3. Splinting

• Neck extension conformer/splint: A custom thermoplastic or foam cervical conformer holds the neck in neutral to slight extension. This prevents the chin from dropping to the chest - the classic neck burn contracture deformity.
  • Worn at all times (during dressing changes and exercises, it may be removed briefly)
  • For deep burns: worn 23-24 hours/day; for cooperative patients with full active ROM: may be worn only at night
• Trunk extension splint: For significant anterior chest burns, a thoracic extension splint or positioning aid keeps the thorax in extension and the shoulders retracted

• Superficial partial-thickness + full AROM: No splint needed
• Deep partial-thickness + decreased ROM: Night splint
• Deep partial-thickness + uncooperative: Splint all times (except during exercise)
• Full-thickness: Splint all times (except during exercise)

4. Range of Motion (ROM) Exercises

1. Passive ROM (PROM) - therapist moves the joint through full range; used initially or when patient is sedated
2. Active-Assisted ROM (AAROM) - therapist assists the patient's own movement
3. Active ROM (AROM) - patient moves independently
4. Resisted/Strengthening exercises - added in later phases

• Neck extension and retraction (priority - counteracts the contracture direction)
• Cervical lateral flexion (ear to shoulder, each side)
• Cervical rotation (chin to each shoulder)
• Cervical flexion (performed cautiously - only to assess range, not to stretch)

• Shoulder flexion and overhead elevation
• Shoulder horizontal abduction and external rotation
• Thoracic extension (arms clasped behind head or "open book" stretch)
• Pectoral stretching (doorway stretch)
• Trunk lateral flexion and rotation

PHASE 2: POST-GRAFTING / SUB-ACUTE PHASE (Wound Closure to 6 Months)

1. Pressure Garment Therapy (PGT)

• Cervical compression collar (also called a neck conformer) - fitted custom to the patient's neck contour
• Chest compression vest - covers the anterior chest

• Worn 23 hours/day (removed only for skin care, exercise, and bathing)
• Continued for 12-18 months (until scar maturation)
• Replaced every 2-3 months as elasticity fades and body shape changes

2. Silicone Gel Therapy

• Silicone gel sheets or topical silicone gel
• Applied to fully closed skin for 12-24 hours/day
• Softens and flattens hypertrophic scars by hydrating the stratum corneum, reducing collagen synthesis

3. Scar Massage

• Firm circular/transverse friction massage using a neutral moisturizing cream
• Duration: 10-15 minutes per area, 2-3 times daily
• Achieves: desensitization of the scar, prevention of adhesions, improved tissue mobility, reduction of pruritus (itch)
• The patient and family/carer are trained in self-massage for home use (PM&R KnowledgeNow)

4. Progressive Stretching and Exercise

• Sustained passive stretching of neck flexors: hold for 30-60 seconds, multiple sets daily
• Pectoral stretching targeting anterior chest tightness
• Progressive strengthening: cervical stabilizers, shoulder external rotators, thoracic extensors
• Aerobic exercise: Introduced progressively - intensive aerobic and resistance training (1 hour, 3×/week) is associated with improved aerobic capacity, muscle strength, physical mobility, and quality of life (PM&R KnowledgeNow)
• Hydrotherapy (pool therapy): Gentle resistance and ROM in warm water - reduces pain during exercise and facilitates movement

5. Continuation of Splinting

• The neck conformer/extension splint is worn at night throughout the scar maturation period (12-24 months)
• Upgraded to dynamic splints if contracture is developing despite static splinting
• Serial casting may be used for resistant contractures - a series of progressively correcting casts applied weekly

PHASE 3: LONG-TERM REHABILITATION (6 Months to 2 Years+)

1. Scar Maturation Monitoring

• Acute: Red, raised, active
• 3 months: Thickened and dry
• 7-9 months: Beginning to soften
• 12-24 months: Mature scar (pale, soft, flat)

2. Surgical Release and Post-Operative Physiotherapy

• Z-plasty: Gold standard for linear contractures - the interdigitating flaps lengthen the contracted area
• Y-V plasty or W-plasty: For shorter contractures
• Full-thickness skin grafts: Replace more dermis, reducing recurrence
• Pedicled/free flaps: For complex recurrent contractures

3. Itch (Pruritus) Management

• Scar massage - direct mechanical reduction of itch
• Compression garments - reduce scar vascularity and itch
• Transcutaneous electrical nerve stimulation (TENS) - for neuropathic itch
• Cold therapy / cooling sprays - temporary relief
• Pharmacological adjuncts: gabapentin (most effective), antihistamines (cetirizine/hydroxyzine), topical menthol creams

4. Functional and Vocational Rehabilitation

• Activities of Daily Living (ADL) retraining: Dressing, grooming, eating - all affected by neck and shoulder restriction
• Work hardening: Progressive work-specific exercises to prepare for return to employment
• Driving assessment: Neck ROM restriction may impact driving safety

5. Psychological Rehabilitation

• Screening for PTSD, depression, and anxiety is mandatory
• Cognitive Behavioural Therapy (CBT)
• Burn survivor peer support groups
• Body image counselling and social reintegration programs

SUMMARY: Physiotherapy Priorities at Each Phase

• Schwartz's Principles of Surgery, 11th Ed. - Burn Depth and Jackson's Zones
• ROSEN's Emergency Medicine - Classification and Diagnosis of Burns
• Tintinalli's Emergency Medicine - Burn Depth Table (Table 217-2)
• Sabiston Textbook of Surgery - Wound Care; Rehabilitation; Early Mobilisation
• ACI Burn Physiotherapy & Occupational Therapy Clinical Practice Guide, January 2025
• PM&R KnowledgeNow - Burn Rehabilitation (AAPMR)
• Brigham and Women's Hospital - Inpatient Physical Therapy Management of Burns