Principles and Practice of Burn Care

Guidelines for Nutritional Management of the Burn Patient
437
appearance is most effective index of nutritional balance.
Estimation of hemoglobin, serum proteins, albumin-globulin
(A/G) ratio, immunological markers–total lymphocyte count
and delayed hypersensitivity are other investigations used
to assess the nutritional status.
The pre-burn weight or ideal weight can be estimated
by using following equations:
For males – 106 lb for 1st 60’’ height +6 lb for each
additional inch
For females – 100 lb for 1st 60’’ height + 5 lb for each
additional inch
Serial measures of resting energy expenditure by indirect
calorimetry, if available, is the best method to assess the
nutritional status as energy requirements vary not only from
patient to patient but also from one burn unit to another,
based on the standards of burn practice.4
NUTRIENT REQUIREMENT AND
DIETARY MANAGEMENT
Nutritional status is directly connected with prognosis and
perspectives of burned patient.
After resuscitation and assessment of nutritional status,
the patient is examined for the presence of diabetes,
hyperlipidemia, any bowel or liver disease, alcohol abuse
and lactose intolerance, etc.
Although early feeding, i.e. within 24-48 hours after an
acute event, is preferred, it is better to rely on IV fluids or
clear oral liquids for first two days as the narcotics used
for pain relief during resuscitation may cause nausea,
vomiting and anorexia. Fluid and electrolyte requirements
are calculated considering the daily maintenance, burn wound
losses, losses due to fever and through gastrointestinal losses
(Table 32.1).
Early parenteral nutrition has no place in Intensive Care
Unit, in patients without pre-existing malnutrition. Early
enteral nutrition is beneficial in patients with major burns.
As soon as the patient is hemodynamically stabile, other
liquids and semisolids are introduced, setting tolerable levels
of intake that supports adequate wound healing and weight
loss.
Protein and Energy Requirements
By the end of the flow phase the patient usually is well
hydrated and has body weight close to the pre-injury weight.
The return of bowel movements is an indication that the
patient can now be slowly introduced to the nutritional
Table 32.1: Nutrition in ICU patients after the patient is out of shock
Main Food Groups
Weight /Measures
Calories
Clear Liquids
Water +Glucose(1tsf)
100 ml
60 kcal
• Orange Juice
200 ml
30 kcal
• Tomato Soup
200 ml
87 kcal
• Soft Drink
200 ml
120 kcal
Switch on to other liquids if patient tolerates
clear liquids i.e. 2,500 ml /day
Other liquids
Milk + 2 tsf sugar +2 tsf protein rich powders
100 ml/hour
2400/24 hours
(commercially available)
Lentil Soup
200 ml
137 kcal
Vegetable Soup
200 ml
100 kcal
Semisolids
Kichadi (Rice with Lentil)
150 gm
190 kcal
Porridge (Dalia)
2 bowls
410 kcal
I/V fluids after 24 hours (maintenance fluid) =50 ml /kg +evaporative water loss
(Evaporative water loss = 4ml/kg × 20 × % burn/100)
Intravenous alimentation till patient is on full diet
Dextrose 10% 1000 ml = 400 kcal
I/V fat preparation 10% 500 ml = 450 kcal
Amino acid preparation 3.5 to 5 % (200 ml) = 1 gm Nitrogen
Total volume = 1900 ml
Non-protein calories = 850 kcal
Calorie-protein ratio = 150/200: 1 gm Nitrogen
6.25 gm protein = 1 gm Nitrogen

438
Principles and Practice of Burn Care
support in the form of oral intake, enteral feeds or parenteral
nutrition. A combination of any two of these routes is
required on a day-to-day basis depending upon the changing
clinical parameters and the severity of burns. Dietary
management should be such as to fulfill the following
objectives:
•
Providing enough calories to prevent subsequent weight
loss.
•
Maintaining fluid and electrolyte balance.
•
Minimizing stress response to pain and anxiety
•
Maintaining a positive nitrogen balance
•
Replenishing the depleted reserves of vitamins and
minerals
•
Preventing Curling’s ulcers, ileus and other complications
Energy
The energy needs of the burn patient varies according to
the depth and size of the burn. According to Robert et al,
of all the major forms of trauma, it is the burn injury that
causes the maximum disorder of metabolism.5 The
requirement is highest in 3rd° burn. Several formulae have
been developed to determine the energy needs. Long’s
modification of HARRY BENEDICT Formula may be used
for calculation of energy needs. However, the results
obtained are not definite as the burned area, its depth,
localization and possible presence of infection are not
included in the formula. Curreri formula is most commonly
utilized and is mentioned below (Tables 32.2 and 32.3).
Calorie requirements should be estimated based on wound
size and patient weight.1
Calories needed per day = 24 kcal × Kg (wt) + 40 kcal ×
% total body surface area (TBSA) burn (Using a
maximum of 50% burn)
The demand of energy in patients with burns may be
very high. It is important to keep a rational balance and not
overload the patient with huge amounts of energy, which
will not be assimilated but accumulated as fatty layer beneath
the skin. As per a study published in 2002 by DW Hart, if
the amount of energy provided is in excess, it leads to greater
complications and increased mortality.6
SCHOFIELD Equation can be used in which calories
are adjusted according to the stress level.
Energy = 25 to 30 kcal/kg body weight/day + adjustment
according to stress level
In Burns Energy = 25 kcal/kg/day + 20 kcal/% burn.
Contribution Towards the Total Energy through
Various Macronutrients/Micronutrients
Carbohydrates
To fulfill calorie requirements, the first priority is given to
carbohydrates which should provide 60-65% of total energy.
Adequate carbohydrate supply reduces protein requirement
for gluconeogenesis and protein is spared for wound healing
and to enhance the immune status. Rate of administration
of glucose should not be above 7 mg/kg/min, as glucose
above this rate will not be utilized to release energy but will
be converted to fat. Blood glucose levels should be closely
monitored to prevent hyperglycemia and its associated
complications.
Table 32.3: Curreri formula II for open wounds (size more then 20% BSA) (Adapted from: Handbook of Burn management,
Ramakrishnan and Hanumadas, 1991)
Age
For Open Wounds— Size More Than 20% BSA
1-3 Years
(100 × kg body weight) + (40 × %) = Kcal/Day
4-6 Years
(70 × kg body weight) + (40 × %) = Kcal/Day
7-10 Years
(60 × kg body weight) + (40 × %) = Kcal/Day
11-14 Years
(50 × kg body weight) + (40 × %) = Kcal/Day
15 Years Onwards
(25 × kg body weight) + (40 × %) = Kcal/Day
Table 32.2: Curreri formula I for open wounds (size less than 20 % BSA) (Adapted from Handbook of Burn Management, Ramakrishnan
and Hanumadas, 1991)
Age
For Open Wounded (Size Less Than 20% BSA)
1-3 Years
(110 × kg body weight) + (40 × % burn) = Kcal/Day
4-6 Years
(85 × kg body weight) + (40 × % burn) = Kcal/Day
7-10 Years
(80 × kg body weight) + (40 × % burn) = Kcal/Day
11-14 Years
(55 × kg body weight) + (40 × % burn) = Kcal/Day
15 Years Onwards
(35 × kg body weight) + (40 × % burn) = Kcal/Day

Guidelines for Nutritional Management of the Burn Patient
439
During the anabolic phase when the patient can eat orally
and has normal bowel movement a combination of simple
and complex carbohydrates may be given. Providing good
amounts of foods rich in mono and disaccharides as well
as starches help in preparing meals which are nutrient dense,
have small volume and are easy to digest. Thus, rice, refined
wheat flour, semolina, sago, arrow root rice, rice flakes,
rice puffs, pasta, dextrose, glucose, honey, potato should
be incorporated liberally in the diet.
Carbohydrates provide 4.1kcal/gm. The number of non-
protein calories given should bear a definite relationship to
the nitrogen intake. The mix should provide approximately
150 kcal/gm of nitrogen or a calorie to protein ratio of 20:1
(normal equals approx 300 cal/gm of nitrogen).
Fats
15-20% of fats is an excellent source of calories (9 cal/gm)
with polyunsaturated fats providing 4% of the total calories
and avoiding a fatty acid deficiency. There is ample evidence
to show that the total number of calories is not the critical
issue, but the composition of the mixture is. For instance,
both carbohydrates and insulin or amino acid administration
have the desirable protein sparing effect. Administration of
lipids should be carried out carefully in all critically ill patients.
Attempting to give all calories by peripheral IV fat
preparations does not spare protein. Not more than 20% of
non-protein calories in the catabolic phase should be fat.
Increasing fat and decreasing carbohydrate percentage in
the diet is particularly helpful in trying to wean a patient
from the ventilator as carbon dioxide production is
decreased. A careful monitoring of immune function, feeding
tolerance and serum triglycerides is required during lipid
administration as it produces thrombogenic and
immunosuppressive effects. Structured lipids and medium
chain triglycerides are currently being preferred. Because
of impaired gastrointestinal function among many patients
it is advisable to lay emphasis on foods rich in emulsified
fat and medium chain triglycerides. Nutritional support with
lipids helps in wound healing, cellular integrity and absorption
of the fat soluble vitamins.
Proteins
It is the most important macronutrient which determines
the ultimate outcome of burns. Sufficient quantity and quality
of amino acids is required to prevent efflux from the skeletal
muscle and maximize protein synthesis for optimal wound
healing and immune function.
Fluid loss from a burn wound may be considerable
and can contain 4-6 gm protein/100 ml, representing 25-
50% of total nitrogen loss. Nitrogen losses via feces have
been estimated to be around 1-3 g N/day. Thus 20-25%
of total calories should be provided as protein in adult
patients.
Protein intakes approaching 1.5 g/kg/day are associated
with net balance between synthesis and breakdown.
High biological value intact protein food sources such
as eggs, milks, cheese, yoghurts, marine food, meat, poultry,
legumes and pulses should be included liberally but in an
easy to digest form.
Calculating Nutrient Requirement
NPC–Non-protein calories
Baseline calorie requirement as per Harris- Benedict Equation:
Males-BEE =66+ (13.7W) + (5H)-6.8A
Female-BEE=55+ (9.6W) +1.8H-4.7A
BEE= Basic energy expenditure
W=Weight in kg, H=height in cm, A=age in years
Shofield Equation= Baseline calorie requirement +/– other
adjustments
= [25 +30 kcal/gm/day + other adjustments according
to stress level (Table 32.4).
Table 32.4: Protein and energy requirement according to
stress level
Stress level
Proteins in gm/kg/day
Energy in kcal/kg/day
Unstressed
0.8
25
Mild
1.2
25-30
Moderate
1.3-1.75
30-35
Severe
2
35-40
Burns
2.0-2.5
25 kcal /kg/day +
20 kcal/% BSA
Other Adjustments (NPC)
Undernourished
+ 10%
Age 18 to 30 years
+ 10%
Fever
+ 10%/degree C rise
Mobile in bed
+ 5%
Mobile
+ 10 %
Obesity
– 10%
Age > 70 years
– 10%
For optimal utilization of proteins, adequate calorie
supplementation is essential.

440
Principles and Practice of Burn Care
Vitamins and Minerals (Micronutrients)
Exact requirements of the micronutrients are not known.
Supplementation is aimed at correcting a deficiency state.
It is generally advisable to give plenty of fresh fruits and
vegetables if an oral intake is feasible. Supplements of calcium
phosphate, zinc and iron are generally required. Packed red
cells may be required to treat anemia. Recommended doses
of vitamins and minerals in moderate and severe burn
patients are given below.
Vitamin C – 500 mg/day
Vitamin K – 10 mg/week
Iron – 10-15 mg/week
Electrolytes
•
Na+: 1 to 2 mmol/kg/day
•
K+: 0.5 to 1 mmol/kg/day
•
Mg++: 0.35 to 0.45 mEq/kg/day
•
Ca++ : 0.2 to 0.3 mEq/kg/day
•
PO4
2– : 20 to 30 mmol/day
(Vitamins: Standard formulae meet broad range of
requirements)
Fluid requirement—Baseline water requirements in adults
may be taken as 30-35 ml/kg/24 hour or approx 1 ml/kcal/
24 hour (25 ml/kg/24 hour for those who are above 65
years).
Additions must be made for fever approx 300-500 ml/
kg/24 hour/degree C above normal and other losses. Fluid
restriction may be indicated in certain disease states such
as cardiac, liver and renal malfunction.
TIME TO START NUTRITION
After 48 hours of fluid resuscitation, depending on the
gastrointestinal status, nutritional supplementation should
begin. Oral route is preferred, supplemented with enteral or
parenteral supplementation. Aim is to prepare the wound
for cover and patient for surgical stress. By the end of one
week vigorous nutritional support should be started to achieve
positive energy and nitrogen balance.
Early versus Late Enteral Nutrition
The time when nutritional support is initiated is also decisive
in the prognosis of burn patients. Proponents of early
nutritional support say that enteral feeding started within
six hours of injury is safe and effective and rapidly reverses
several of the most important metabolic and hormonal
effects of burns.
It was stated above that enteral feeding of the burned
patient should be started only after the period of shock is
over, i.e. the second or even the third day after the burn.
Recently, an early enteral nutrition has gained more support.
It must be started in six hours after burns. In developing
countries, it is difficult to treat and dress all the burn patients
in isolated wards and assure the medical care in aseptic
conditions. While treating severe deep burns, the problem
of wound covering and donor areas also arises. Consequently
administering the enteral nutrition earlier helps in reversing
the most important metabolic and hormonal effects of burn.
First studies showing advantages of an early nutrition were
conducted in 1994. Gianotti has shown that early enteral
nutrition lessens the translocations of bacteria.7 The study
published by Wang (1997) showed that early enteral nutrition
lessens catabolism after burn. The need for energy in burned
patients was studied, as well as glucagon, serum insulin,
urine cortisol and catecholamines. Decrease of these indices
has been proven to be statistically reliable in the group with
an early enteral nutrition compared to the later enteral
nutrition group.8
It is recommended to start enteral nutrition with
hypocaloric mixture (0.5 kcal/ml) at the rate 25 ml/hour. If
nutrition is well tolerated by patient, the rate is increased by
25 ml at every 8 hours, to 100-120 ml per hour.
Once we are aware of the nutrient requirements of an
extensively burnt patient, let us take a closer look on the
methods we can use to feed our burn patients.
Modes of Feeding/Nutritional Support
Oral Dietary Support
Oral feeding should always be encouraged and attempted,
if tolerated by the patient as this is the most convenient and
natural way of feeding. Other modes of feeding should be
used only if this route is ineffective or cannot be used.
Diets should be designed to give the calculated calorie value
and protein. Acceptable protein intake can be obtained with
selective high protein, high calorie diet and with additional
supplements of high protein liquids between meals.
Concentrated oral liquids with protein hydrosulfates or
amino acids must be given to ensure adequate intake (See
Appendices 2.1 to 2.3).
Most of the patients are depressed and may need
encouragement by family and medical team to promote
adequate food consumption. Food should be attractive and
appetizing and individual likes and dislikes must be
considered. It should include all the nutritional requirements.

Guidelines for Nutritional Management of the Burn Patient
441
Meals should be served at regular intervals. The importance
of adequate nutrition should be explained and stressed to
the patient and his/her relatives.
We should start with liquid diet and gradually switch to
semi solids and then solid foods in 4 to 5 days. Cleanliness
in the preparation and serving is of paramount importance
to avoid GIT disorders. Enfeebled patients and patients with
burned upper extremities require assistance. Excessive
lactose in diet may precipitate post-traumatic lactose
intolerance leading to bloating of the abdomen, flatulence,
cramps and diarrhea. Burns of oral cavity may preclude
feeding by oral route and may require alternate route of
nutrition. Moreover, oral feeding solely cannot meet the
elevated calorie requirement.
Anabolic steroids such as oxandrolone are often
combined with high protein diet to promote weight gain
and enhance anabolism in these patients.
Enteral Nutrition by Tube Feeding
Administration with nasogastric tube is recommended as
this is most physiological. If large amounts of enteral
mixtures need to be administered, nasoduodenal or
nasojejunal tubes may be used. For long term enteral
nutrition percutaneous gastrostomy may be planned.
Enteral nutrition can be judicially used in patients with
good bowel functions to meet the extra calorie and protein
requirement for more than 20% body surface area of burn
patients. It is also indicated in patients who are unable to eat
or unwilling to eat due to reasons like sepsis, endotracheal
intubations, following anesthesia, etc. Maximum calories
that can be provided through this method are limited to
3000 kcal/day combining the calories from protein and non-
protein sources (Table 32.5). Small bore tube which is well
tolerated and allows for oral feed is preferably used in our
center. Small amount (0.5 -1 ml/kg/hour) of low bulk iso-
osmolar formula is started initially and gradually the amount
is increased. Most of the tube feeding formulae contain a
high protein diet homogenized in a blender with milk and
supplemented with some type of commercial protein
preparation. Eggs, 1 tsf of honey and cube of butter may
be added to it. Small feeds should be prepared and given at
frequent intervals till calculated volume for 24 hours is
achieved. Feeds exposed to room temperature for more
than 8 hours should be discarded. Gastric contents should
be aspirated every time the feed is given. Gastric residue
after 4 hours should not exceed 150 ml or else the feeding
should be postponed.
Enteral nutrition can be administered as bolus feeds or
by a constant delivery pump. Ideally enteral nutrition can
be started at a rate of 15 ml per hour of full strength formula
and increased stepwise by 15 ml per hour every 12 hours
to reach up to 100 ml/hour. An antiemetic may be added to
decrease gastric residual volume.
Instructions to be followed during Enteral Nutrition
•
Feeding tube to be placed by expert
•
Check position of feeding tube by X-ray.
•
Head to be elevated to 30 degree during feeds.
•
Aspirate the tube before every feed or 4 hourly if on
continuous drip.
•
If aspirate < 150 ml return aspirate and start feeding.
•
If > 150 ml reduce feeding rate or increase the time
interval.
•
Irrigate tube with water after every feed or 4 hourly.
•
Intake/Output charts to be maintained.
•
Electrolytes, serum proteins, kidney and liver function
tests to be done twice a week
•
Weigh the patient on alternate days
•
Once the iso-osmolar formula is tolerated, hyper-osmolar
formula may be tried to attain 1kcal/ml. Continuous drip
using a mechanical pump may be used for feeding. The
feedings are changed to oral dietary support as soon as
the patient can take adequate oral diet.
Oral tube is most preferable choice but may not be
possible in uncooperative and unconscious patients. Naso-
gastric tube feeding is given to patient with swallowing
impairment with intact small bowel.
Table 32.5: Approximate combinations of nutrients in Enteral
Feeds9
Protein(nitrogen)
Normal
Burns
10 to 16 gm
16 to 20 gm
Carbohydrate
1000 cal
1200 cal
Fat
1000 cal
1200 cal
Total calories (non-nitrogen)
2000 cal
2400 cal
Total volume
2.5 liters
3 liters
Adverse Effects of tube feeding include vomiting,
diarrhea, abdominal distention, dehydration, gastric dilatation
and aspiration. Monitoring of fluid balance, osmolality and
electrolyte status is required to avert the adverse effects.
Rectal examination should be done to exclude fecal impaction
which may lead to overflow diarrhea. Adequate nursing care
to administer tube feeding without complications is absolutely
essential. Prokinetic drugs such as metoclopramide may be
used.

442
Principles and Practice of Burn Care
Enteral feeding offers many advantages over parenteral
feeding. Oral feeds help in maintaining integrity of mucosal
cell mass which prevents endotoxins and bacterial
translocation to the systemic circulation. It also maintains
the secretion of digestive enzymes and trophic hormones
particularly gastrin which promotes insulin secretion and
anabolism.
Parenteral Nutrition (See Appendix 2.4)
Parenteral feeding is required in the following situations:
•
In combination with oral/enteral feeds and extensive
burns more than 40% TBSA or deep burns more than
20% BSA to meet high calorie needs.
•
Gastrointestinal dysfunction or paralytic ileus.
•
Patients with septic complications or inhalation injury.
•
Patients on ventilatory support.
•
Patients undergoing aggressive fluid resuscitation who
are at risk for poor intestinal perfusion. Parenteral
nutrition can be given by
1. Peripheral vein
2. Central vein
Parenteral support via a peripheral vein is considered
while increasing the oral/enteral support to the desired goal.
For parenteral nutrition, a central vein is preferred over the
peripheral veins because of non-availability of peripheral
veins in chronic burn patients and early development of
thrombophlebitis in peripheral veins following administration
of hyperosmolar solution.
The advantages of peripheral vein cannulation are:
•
Convenient insertion and maintenance
•
Lower incidence of mechanical and infectious
complications
•
Short term parenteral nutrition of less than 7 days
•
Partial (supplementary) parenteral nutrition
•
Temporary in the absence of technical expertise
Choose a large vein away from injury.
Advantages of parenteral feeding via central vein are:
•
When calorie intake via other routes is insignificant or
nil or
•
When hyperosmolar liquids have to be given to meet the
calorie requirement in extensive burn patients, it is easier
to give via central vein as it does not cause thrombo-
phlebitis.
The ideal vein for central venous access is Subclavian
vein; internal jugular vein is second best choice, Femoral
vein is best avoided though still used frequently.
One cannula or one lumen of cannula should be dedicated
for parenteral nutrition only. No other medication should be
given through it; blood should not be drawn from this (except
for the purpose of culture)
Disadvantages of central vein catheterization are:
•
Insertion and maintenance needs expertise
•
Higher incidence of infectious and mechanical
complications
Central veins are therefore used in:
•
Prolonged parenteral nutrition of more than 7 days
•
Total Parenteral Nutrition
•
Peripheral vein not accessible.
Investigations to be done before starting total parenteral
nutrition (TPN)
Hematological
•
Blood sugar
•
Blood urea/serum creatinine
•
Serum Albumin
•
Magnesium, Calcium, Phosphorus, Lipid Profile
•
Prothrombin time
•
Liver function tests(Bilirubin and Enzymes)
•
Urine analysis
•
Serum electrolytes (Na+, K+, Cl-, HCO3
-)
•
Coagulation Profile
Optimization of fluid and electrolyte status is mandatory
before starting TPN. Daily monitoring of blood chemistry
is required along with body weight and fluid balance.
TPN can be given as separate components of
commercially available preparations of protein, fats and
carbohydrate or as premixed multicomponent solutions
which are now available and have reduced the potential for
error and metabolic aberration see Appendix 2.5 (Tables
2.5A and B).
Maximum rate of dextrose administration should be 4-6
mg/kg/min to avoid the risk of hyperglycemia.
If carbohydrates are given as the only source of energy,
they can lead to:
•
Deficiency of essential fatty acids
•
Deficiency of fat soluble vitamins
•
Excess CO2 load
•
Hepatic steatosis
•
Increased osmolarity of solution.
Instruction charts should be maintained stating the following
details of parenteral nutrition.
•
Total energy calculated on body weight basis.
•
Substrate distribution ( volume of carbohydrate, fat and
protein)

Guidelines for Nutritional Management of the Burn Patient
443
•
Fluid volume.
•
Rate of delivery.
•
Hang time.
•
Total time frame.
•
Steps to be taken in case of accidental change in rate of
delivery.
It is said that to prevent the complications of parenteral
feeding, like over feeding of intravenous nutrients which
may leads to hepatic disorders, fluid retention and metabolic
derangements, the required volume for the parenteral
nutrition is determined by the rate of substrate utilization as
opposed to a predetermined energy goal, as demand of
energy may reach to 50 Kcal/kg/day. It is important to keep
a rational balance and not overload the patient with huge
amounts of energy.
The maximum oxidation of glucose in liver is when given
at a rate of 4-6 mg/kg/min. If given beyond this rate, it is
not assimilated but deposited as fat beneath the skin.6
Proteins at 2.5-4 gm/kg can be given, increasing
gradually to the desired goal.
20% Fat preparations are not given during acute phase
of shock. Starting with 0.5 gms/kg/hour, the maximum rate
of 1.0 to 1.5 gm/kg/day should not be exceeded when given
during the recovery phase.
The daily volume for TPN requirement is calculated on
the basis of;
•
All on-going losses, including insensible loss
•
Input–output chart
•
Alternatively , 30 to 40 ml/kg body weight
•
Caution in patients with renal dysfunction and congestive
heart failure
For infants and children < 20 kg =1.7 ml/kg/hour
For children> 20kg =1.5 ml/kg/hour.
This is started at 60 ml/hour and increased to 80 to 100
ml/hour after 4 to 6 hours. PN should ideally be given during
the day time. Lipid emulsions when given alone should be
completely infused within 12 hours of hanging. Lipids when
administered as total nutrient admixture can be hung for 24
hours.
If parenteral nutrition is interrupted due to any reason,
clear instructions should be stated to administer 10% dextrose
solution at the same rate to prevent sudden hypoglycemia
caused by high endogenous insulin. Complications of
intravenous hyperalimentation are greater than with enteral
route.
Complications of Parenteral Nutrition
Mechanical –Related to catheter placement or thrombosis
Infectious–Bloodstream or catheter site infections
Metabolic
•
Hyperglycemia
•
Hypertriglyceridemia
•
Fluid, electrolytes and acid base disturbances
•
Asymptomatic rise of serum hepatic transaminases
•
Re-feeding syndrome.
Re-feeding Syndrome
It is a rare life-threatening syndrome, seen when
carbohydrate-rich feeding is started in severely malnourished
patients. It is characterized by massive influx of electrolytes
inside the cells resulting in hypokalemia, hypophosphatemia
and hypomagnesemia. The precautions to be taken in such
patients are providing only half the calorie needs of one
day, administration of thiamine (250 mg in 100 ml 5%
dextrose IV over 30 minutes) before starting PN and
aggressive electrolyte monitoring.
Warnings and Precautions for PN Use
Patients on parenteral nutrition may develop severe egg
allergy or allergy due to high levels of triglycerides (> 400
mg/dl). Rapid infusion of lipid emulsions can cause fever,
chills, tachypnea, wheezing, palpitations and vomiting, etc.
Discontinuation of PN is required in such conditions of
severe allergy.
Weaning of Parenteral Nutrition
•
Stop TPN when enteral feeding can restart
•
Wean slowly to avoid hypoglycemia
•
Monitor hypoglycemia during weaning
•
Give IV dextrose 10% solution at 100 ml/hour rate for
at least 4 to 6 hours
•
Alternatively, wean TPN while introducing enteral feeding
and stop when enteral intake meets total energy
requirement
•
In case PN is to be stopped for some other reason (e.g.
a complication), the same protocol of dextrose infusion
(10% dextrose @ 100 ml/hour × 4-5 hours) is followed.
Biological Value (BV) related to how much of the protein
consumed is actually absorbed, retained and used in the
body. More specifically, biological value is the measure used

444
Principles and Practice of Burn Care
to rate protein quality through nitrogen retention in human.
Higher the quality of protein more is the nitrogen absorbed
and retained by the body.
Nitrogen Balance: Of the three energy nutrients,
carbohydrates, fats and proteins only proteins contain
nitrogen. Everyday we excrete nitrogen in our sweat, urine,
feces and from open wounds when present. Every hour of
the day we are in a state of nitrogen flux. Our body is either
in positive, negative or zero nitrogen balance. Zero nitrogen
balance is an equilibrium state where the nitrogen we ingest
from protein equals the nitrogen we loose. Just before we
go into zero nitrogen balance, we must have been in a positive
nitrogen balance. This is where nitrogen absorbed and
retained exceeds nitrogen used and lost. Only during positive
nitrogen balance can our body repair and rebuild muscle
tissue, effectively fight infections, recover from illness,
handle stress and thereby stay healthy.
In a burn patient, there is an excess of loss of nitrogen
from the burn wound and if this excessive demand is not
met with, the patient goes into negative nitrogen balance,
i.e. catabolic state.
Free Amino Acids versus Intact Proteins
Free forms of amino acids actually compete with one another
for their uptake through the intestinal lining. This competition
limits the rate of absorption because ingested free form of
amino acids compete with each other for absorption; they
can overwhelm available transport mechanism, therefore,
reducing total amino acid absorption. These amino acids
result in the poorest nitrogen retention, and are hence, the
least anabolic. Some of these free amino acids have another
drawback. They increase intestinal osmotic pressure, which
can interfere with the absorption of all the nutrients and
lead to diarrhea and intestinal distress.
Proteins that are partially hydrolyzed to form peptides
are the most anabolic form of dietary supplements and are
absorbed faster than either single amino acids or whole
proteins. They create the highest nitrogen retention and do
not cause intestinal problems.
ASSESSMENT OF NUTRITIONAL SUPPORT
It is very important to evaluate the efficiency of given
nourishment because insufficient nutrition impairs wound
healing. Evaluation of nutritional state of the burned patient
should be done by clinical analyses. First sign of insufficient
nutrition is fatigue of patient while performing everyday
procedures, as well as during physiotherapy. Tolerance to
enteral nutrition should be constantly observed and in case
of tube feeding remaining volume of food in stomach should
be measured and intestinal transit should be observed.
1. Intake records gives idea of daily protein and calorie
intake.
2. Daily weight record is a simple method of assessing
effectiveness of nutritional support. However, it may be
inaccurate due to bulky dressings, fluid shifts, excision
and amputations. Sometimes, it is difficult to weigh a
sick patient.
3. Immunological markers may be unreliable for assessing
nutritional status.
4. Serum albumin levels or transferrin can be easily
assessed.
5. Nitrogen balance studies –consistently elevated blood
urea nitrogen (BUN) may indicate deterioration in renal
function or increased protein catabolism. Very high BUN
is an indication to reduce protein in the diet. If there is
no insufficiency of renal function, nitrogen balance is a
good indicator of nutritional state and efficiency.
Nitrogen balance is a difference between obtained and
lost nitrogen (N). In practice, excreted nitrogen is
measured only in urine but it is necessary to specify
nitrogen loss while including other physiological ways
of excreting nitrogen e.g. excretion from hair and
through skin in exudation.
Nitrogen loss = N lost with urine + 8 mg/kg body + 0.2 gm
N/% body surface burned.
N urine = (urea in urine x 0.08)/2.14 + 4 gm.
Here 0.08 is a coefficient to convert urea from gm/L
into mmol/l, 2.14 is a coefficient of recalculations used to
find out the level of nitrogen in urine from urea level in
urine.
Nitrogen Balance NB = NI (nitrogen intake) – nitrogen lost
in (U+F+S) (urine, feces and skin)
On the first day, blood sugar is measured every 6 hours
for 24 hours. During the first week, serum electrolytes,
blood urea, sugar and triglycerides are measured daily.
Unstable patients may require their blood sugar and serum
electrolytes measurements as often as twice a day. Serum
calcium, bilirubin, alkaline phosphatase, phosphorus,
magnesium and blood counts should be done at least twice
a week.
Liver profile and enzymes estimation of serum, trace
elements and serum transferrin are done once a week.

Guidelines for Nutritional Management of the Burn Patient
445
NUTRITIONAL ASSESSMENT CHART
See Appendix 2.6 for Stepwise Calculation of Nutritional
Requirement.
Surgeons and Residents involved in management of
Burns should learn to prescribe a nutritional regimen in a
methodic and scientific manner as follows:
1. Before starting nutritional support, patients with shock
should be adequately resuscitated and gross fluid and
electrolyte imbalance corrected. Mild degree of fluid and
electrolyte imbalance can be corrected with ongoing
nutritional support.
2. Decide on the route of administration for nutrition, plan
the oral/enteral/or parenteral nutrition or partial parenteral
nutrition.
3. Calculate the energy requirements of burn patients
according to Curreri formula depending on the size of
burn wound and age of the patient.
4. These formulae or equations for calorie estimation often
overestimate the calorie requirements.
5. To avoid this and simplify it, one can easily calculate the
calorie protein needs according to appropriate stress level
taking the severity of disease into consideration.
6. Calories are derived from three major substrates –
carbohydrates, fats, and proteins. By and large 50% of
calories are derived from carbohydrates, 30% from fats
and 20% from proteins. In critically ill patients, certain
adjustments are required as mentioned earlier.
7. After finalizing the total calorie and substrate
requirements, the total permissible liquid intake has to
be calculated. Normal recommendation is 30-40 ml/kg/
day. However, liquid intake has to be adjusted in specific
conditions such as renal and cardiac failure, where
volume load needs to be restricted. Consequently, total
calories will have to be given in restricted volume of
fluid. In patients on total parenteral nutrition, this
becomes a challenge and one will have to resort to using
more lipid emulsions as they give higher calories on
weight to weight basis.
NUTRITION IN SPECIAL CONDITIONS
Pulmonary Conditions
Increased administration of glucose in burn patients > 4 to
6 mg/kg/hour results in increased CO2 production. Hence,
a patient with ventilatory impairment receiving high
carbohydrate diet will have harmful effect on pH and
respiration. Instead such patients are benefitted by low
carbohydrate and high fat diet. Fat should provide 30 to
50% of non-protein calories.
Renal Conditions
Due to massive catabolism in burn patients there is increase
in uric acid, potassium, phosphorus nitrogenous wastes.
Blood urea nitrogen may increase and complicate the
metabolic and nutritional management. Blood urea nitrogen
should be kept below 100 mg/dl with protein restricted diets
and dialysis. Protein restricted diets containing only essential
amino acids may be tried. 0. 6 to1gm/kg/day protein is given
initially and gradually increased each day to achieve the
tolerated goal. Monitoring the daily increase of BUN levels,
if BUN levels increases more than 30 ml/dl/day, amino acids/
proteins supply must be reduced and one may consider
modified amino acid compositions.
Due to oliguria and hyperkalemia, fluid and potassium
restriction is advised in renal failure. Citrus fruits and IV
fluids with potassium e.g. Ringer lactate is restricted. If IV
fluids are required 5% dextrose saline is preferred. Fluid
requirement is calculated on the basis of loss due to burns
plus previous day’s output. Phosphorus and potassium
binders may be used orally.
Because of fluid restriction, optimum non-protein
calories are provided with concentrated glucose and lipid
solutions. There is reduced glucose tolerance and increased
insulin resistance in presence of acute uremia and acidosis
hence blood glucose levels should be monitored closely in
patients with acute renal failure (ARF). Although there are
benefits of using lipids as source of energy in patients with
ARF, the intake should be limited to 25 to 30% of total
energy.
Hepatic Conditions
In patients with chronic liver disease, aromatic amino acids
may lead to hepatic encephalopathy. Supplementation with
branched chain amino acids is beneficial in such patients.
Milk (casein) and vegetable protein diet should be preferred
to meat protein diet with rate of 0.6 gm to 1 gm/kg/day.
However, patients with alcoholic liver disease may
benefit from early nutritional support by providing adequate
calories, proteins, minerals and vitamins. In the presence
of hepatic encephalopathy the total protein intake should be
reduced to 0.5 gm/kg/day or even less.
ADJUVANT THERAPY TO MODULATE ENERGY
REQUIREMENT AND PROMOTE WOUND HEALING
Environmental and clinical factors that influence
metabolism and hence energy requirement
The magnitudes of inflammatory responses are
proportional to the severity of trauma and are not preventable.

446
Principles and Practice of Burn Care
However, various clinical interventions can affect or amplify
this metabolic rate further influencing energy requirements.
Due to the combined effects of inflammation and
evaporation, the burn patients are amongst the most
hypermetabolic. Occlusive dressings, early excision and
grafting help in minimizing this effect.
Environmental measures to minimize heat loss by
warming the external environment, pain management,
sedation, ventilatory support and nutritional therapy
contribute to patient’s overall energy expenditure. For
example a patient, who has good pain control, is well sedated
and working little towards the effort of breathing while
mechanically ventilated may have lower requirements than
a patient who is less critically ill, breathing on his/her own
with less sedation and with more participation in
rehabilitation. Shizal and Forse documented that
carbohydrate was more efficient in diminishing weight loss
and protein degradation after injury.
1. Hormonal Therapy
Studies have been done on recombinant Human growth
hormone which is a potent anabolic agent.10 Mortality and
morbidity in burns is directly proportional to severity of
protein catabolism leading to delay in wound healing, sepsis
and multiorgan dysfunction.11 The hypermetabolic state is
related to increase in catabolic hormones and decrease in
anabolic hormone.12-14
Recombinant growth hormone (rhGH) supplementation
in the doses of 0.5 IU/kg/day for 2 weeks together with
standard conservative management of burns have shown
to arrest severe catabolic state of burns and hence avoid
weight loss. Increase in serum albumin and hemoglobin
with rhGH treatment further support the anabolic effect of
rhGH. The administration of growth hormone also results
in marked augmentation of nitrogen retention, decreased
BUN and serum basal insulin almost doubles. There exists a
close relationship between nitrogen balance and basal insulin
secretion and increased insulin augmentation appears to be
the controlling mechanism for the improved nitrogen
retention.
2. Immunotherapy
Use of Immunoglobulins (particularly enriched with IgM)
in burns is now being studied extensively.
It was earlier believed that the task of the immune system
was restricted solely to recognition and elimination of
viruses, bacteria and their toxins. Today, it is regarded as
an organ system which is complex, self regulating and in
communication with other systems.
Pentaglobin i.e. IgM enriched intravenous
Immunoglobulins have an anti-bacterial, anti-toxic, anti-
inflammatory, and immune modulating activity.
The magnitude of inflammatory responses, however, is
proportional to the severity of trauma. Adjuvant therapies
like giving immunoglobulins can help modulate inflammatory
responses, hence affecting metabolic rate which further
influences energy requirements. The rate of metabolism
increases with onset of wound sepsis leading to an increase
in protein and energy requirement. Pentaglobin used
concomitantly with antibiotics especially against gram +ve
and gram –ve bacteria and their toxins indirectly help in
reducing rate of metabolism.
3. Role of Albumin in Burns
Albumin is a naturally occurring plasma protein and has
long been thought to be the kind of solution by which
patients would most benefit (defined as a “gold standard”).15
Commercially available human albumin solutions (HA)
contain 96% of albumin. Purified protein fraction contains
approximately 83% albumin.
The molecular weight of albumin is 69,000 Daltons
(approx.). 4% albumin is slightly hypo oncotic, 5% albumin
is iso oncotic, whereas 20% and 25% solutions are markedly
hyper oncotic, so that total plasma volume is expanded by
shifting of fluid from the interstitial/intercellular to the
intravascular compartment. 100 ml of 25% albumin increases
intravascular volume to a total volume of approximately
450 ml.16
The volume effect of albumin is not predictable and
depends on blood volume, proteins level and capillary
permeability.
The serum albumin concentration is a function of its
rates of synthesis and degradation and its distribution
between the intravascular and extravascular compartments.
The total body albumin pool measures about 3.5 to 5.0 gm/
kg body weight (250-350 gm for healthy 70 kg adult). The
plasma compartment holds about 42% of this pool, the rest
being in extravascular compartment. Some of this is tissue
bound and is, therefore, unavailable to the circulation.
Critical illnesses like burns alter the distribution of
albumin between the intravascular and extravascular
compartments. There are also changes in the rate of synthesis
and degradation of the protein. The serum albumin
concentration often decreases dramatically early in the
course of critical illness. It does not increase again until

Guidelines for Nutritional Management of the Burn Patient
447
recovery phase of illness. The kinetics of albumin given IV
differ greatly between critically ill patients and healthy
subjects. The implication of this fact, given the important
functions albumin has in health, is that using exogenous
albumin to increase the intravascular albumin concentration
during critical illness is beneficial.
Unfortunately, studies have failed to show any benefit
of albumin over other colloidal therapies in adult.
The altered distribution in critical illness is related to an
increase in capillary leakage. This occurs in sepsis, burns
and after major surgical stress. It involves dysfunction of
the endothelial barrier, resulting in capillary leakage and loss
of protein, inflammatory cells and large volumes of fluid
into interstitial space.
The rate of albumin synthesis may be significantly altered
in the critically ill. In the acute phase response to trauma,
burns, inflammation or sepsis, there is an increase in the
gene transcription rate for the positive acute –phase proteins
such as C-reactive protein, and decrease in the rate of
transcription of albumin mRNA and the synthesis of albumin.
IL-6 and TNF-α both act to reduce gene transcription. A
sustained inflammatory response in critical illness may lead
to prolonged inhibition of albumin synthesis.
Catabolism of albumin may also be altered.
Indications for albumin administration:
1. Volume replacement therapy: At present there is no
evidence from randomized controlled trials that
resuscitation with albumin and plasma protein fraction
(PPF) improves survival, compared with resuscitation
with cheaper alternatives such as saline, in patients with
hypovolemia, burns and hypoalbuminemia, except in
highly selected populations of critically ill patients.
2. Support of colloid oncotic pressure: It is believed that
the oncotic force of concentrated human albumin may
help reduce tissue edema. Recent literature states that
albumin may exert a direct protective effect in the
critically ill patient and its ability to sustain oncotic
pressure may only be one of many possible mechanisms.
3. Maintenance of serum albumin levels: The normal serum
concentration of albumin is 35 to 50 g/l: Albumin appears
to be a non specific marker of the seriousness of an
illness.
4. As a transport molecule for various drugs and endogenous
substances and also acts as an effective plasma buffer.
5. To assist in coagulation: Albumin is involved in the
coagulation pathways and has an anticoagulant effect
which is probably antithrombotic in nature.
6. Free radical scavenging and maintenance of membrane
integrity.
7. Management of fluid shifts
-
As an osmotic agent
-
To redistribute fluid during dialysis
-
To improve oxygenation
8. Miscellaneous - to correct metabolic acidosis
-
Neonatology ICU.
-
Liver disease, ascites, malnutrition
-
Starvation
-
Nephrotic syndrome
9. Severely burned ICU patients: These patients are a
specific group in whom albumin may have a beneficial
role. Though it is reported to be harmful in first 24 hours,
its use is justified after 24 hours in profoundly hypoal-
buminemia patients as it favors resorption of edema.
In burns covering < 15% of body surface area, it may
not be necessary, but its use is justified in > 50% TBSA
burns. When using albumin in burn patients, synthetic
colloids (e.g. hydroxyethyl starch) have been shown to be
effective or even superior in increasing CVP, PCWP, DO2
and VO2. Surprisingly one study says that no attempt should
be made to normalize serum albumin levels in burns. Albumin
plasma levels as low as 15 g/l have been seen to be well
tolerated in these patients.
Side Effects of Albumin
There are several reasons why albumin supplementation
might make things worse for critically ill patients.
1. Cardiac decompensation may occur after rapid volume
replacement with 20% albumin as it leads to four fold
increase in volume retention.
2. In patients with capillary leak syndrome, albumin may
become detrimental when albumin and water cross the
capillary membrane and cause or worsen pulmonary
edema, thus compromising tissue oxygenation and finally
leading to multiorgan dysfunction.
3. The anti-hemostatic and platelet lowering properties of
albumin may increase blood loss in postsurgical or
trauma patients.
4. Albumin administration in the resuscitation of
hypovolemic shock may impair sodium and water
excretion and worsen renal failure.
5. Commercially available preparation of albumin contains
aluminium and may lead to toxic concentration of ions.
Despite a growing body of systematic reviews, evidence
based medicine analyses and consensus, conferences, the
utility and safety profile of albumin is still under dispute.

448
Principles and Practice of Burn Care
Human Albumin Replacement Therapy in Burns
1. In cases of extensive and severe burns with an increased
hematocrit value, normalization of the circulatory conditions
can be approached in a very efficient manner with Human
Albumin 20% or 25% Immuno diluted with dextrose, levulose
or electrolyte solutions with recommended doses:
Adults: 200 to 400 ml Human Albumin 20% Immuno
(40-80 g) diluted 1 in 4, corresponding to 800 to 1600 ml
of 5% albumin solution.
OR
200 to 400 ml (50 to 100 gm) of Human Albumin 25%
diluted to 1in 5 with isotonic electrolyte or dextrose solutions
(corresponding to 1000-2000 ml of 5% of albumin solution)
Children: 4 ml Human Albumin 20% per kg body weight
Immuno diluted 1 in 4 corresponding to 16 ml of 5% albumin
solution
The total dosage over the 24 hours can be determined in
accordance with the formula:
2 ml × body weight (kg) × % of surface burn + 1500 ml
2. After the acute stage has been brought under control
considerable protein deficiency, largely of albumin may
occur. This hypoalbuminemia can be corrected by
administration of the following doses:
Adults: 50 ml Human Albumin 20% Immuno (10 g)
twice a day
Children: 1 ml Human Albumin 20% Immuno (0.29 gm)
per kg body weight.
Additional loss of protein and diminished albumin
synthesis might lead to severe albumin deficiency. In
debilitated patients stabilization of the protein balance with
Human Albumin 20% Immuno may considerably improve
the general condition of the patient.
4. Role of Immunonutrition/Immunomodulators
in Burns and Critically ill Patients
The link between malnutrition and impaired immune function
has been well documented. The importance of some specific
nutrients in burns is proved and these substances have got
special attention in recent years. They are called
immunomodulators. It is determined that these substances
have a positive effect on protein metabolism, immune state
and function of intestines. These nutrients known as
“immunonutrients” include amino acids arginine and
glutamine, Omega-3 fatty acids, nucleotides and antioxidants,
vitamins and minerals.
Recently much thought has been given to glutamine as
an immune enhancer. Glutamine is an amino acid which
can be synthesized by virtually all the tissues and it accounts
for more than 60% of body free aminoacid pool. During
starvation and particularly during stress the glutamine pool
of the body is reduced markedly.
Glutamine has many pharmacological effects. In
experimental study by Furst 17, it was shown that keeping
nourishment rich in glutamine in catabolic conditions gives
a positive effect on nitrogen balance, protein synthesis,
decreases proteolysis in muscles, helps to retain integrity
of digestive tract, protects from translocation of bacteria,
decreases number of complications as well as mortality.
The study of Zhou (1999) determined that supplementing
glutamine in early stage after burn in doses of 0.5 to 1 gm/
kg decreased the risk of complications and improved wound
healing. Arginine is also known as a substance affecting
metabolism and immunity.
Cyober18 recommends administering α-ketoglutarate
two times per day, altogether 10 gm (two bolus every 12
hours); it decreases catabolism of muscles and myofibril
proteins, saves glutamine in muscle, decreases catabolism
in intestine and stimulates protein synthesis in liver after
burn.
Omega-3 fatty acids (FA) have anti-inflammatory effect;
they inhibit interaction of blood vessels endothelium with
leucocytes, inhibit synthesis of interleukin 1 and 6. Ratio of
omega-6 FA and general FA level is important because
synthesis of prostaglandins or leukotriens predominates
depending on the ratio. After burns, mixtures of
Immunomodulators can be used, glutamine, arginine,
α-ketoglutarate, omega-3 fatty acids, selenium zinc
cocktails. They can be used as stable mixtures for enteral
nutrition.19,20
Current thinking is to avoid Immunonutrition in life
threatening septic patients with APACHE scores more than
20, where such radical changes in nutrients may perhaps
adversely affect the outcome. Instead use it in less serious
patients of sepsis or in early sepsis where it is more likely to
be of benefit.
5. Role of Environmental and Clinical Factors
There are lots of environmental and clinical factors that
influence metabolism and hence, energy requirements. The
initiator of the metabolic response to thermal injury is a
large defect. Hence, every effort should be made to promote
wound healing and establish a properly functioning surface

Guidelines for Nutritional Management of the Burn Patient
449
barrier and interface between patient and surrounding
environment.
Adequate nutritional support along with closure of wound
is associated with a rebuilding of body mass, gain in weight
and the patient’s return to an active productive life.
6. Role of Early Physiotherapy
Physical activity leads to deposition and incorporation of
amino acids into skeletal protein. With the help of a
physiotherapist, a planned exercise programme must be
instituted as soon as possible in burn patients. Simple
isometric exercises can be accomplished to improve the
vitality of muscles and encourage the movement of nitrogen
to skeletal muscle cells once the calorie and nitrogen
equilibrium is achieved.
SUMMARY
Apart from the medical and surgical needs of a burn patient,
the nutritional aspect should also be given equal importance
as nutritional care complements the medical and surgical
treatment of any burn patient. Nutritional requirement is
met not only by carbohydrates, fat and proteins but also by
adjuvant hormonal therapy and immunotherapy. Protein
catabolism and mobilization of body fat occurs due to
hormonal signals that summons these substrates, apparently
for wound healing and energy utilization following burn
trauma. The signal for substrate utilization or storage is
basically an interaction between insulin and catecholamines.
Food intake by the patient stimulates insulin production
which diminishes the catabolic effects of increased nervous
activity and favors protein biosynthesis and glycogen
storage. Judicious and early administration of enteral or
parenteral feeds in a burn patient goes a long way in reducing
the morbidity and mortality in major burns.
REFERENCES
1. Mathangi Ramakrishanan K. Handbook of Burns Management
Jaypee Brothers 1991 1st edition 61-65.
2. Carlson DE, Cioffi WG, Mason AD, McManus WF, Pruitt BA.
Evaluation of serum visceral protein levels as indicator of nitrogen
balance in thermally injured patients. JOEN, 1991:15, 440-001.
3. Rafuso CA, Dupertuis YM, Pichard C. The role of visceral proteins
in the nutritional assessment of intensive care unit patients. Curr
Opin Clin. Nuts Metal Care 2003: 6, 211-6.
4. Cunningham JJ, Hegarty MT, Meara PA Burke JF. Measured and
predicted calorie requirement of adult during recovery from severe
burn trauma. Am. J. Clin. Nutr 1989: 49,404-8.
5. Robert H, Demling MD, Leslie De. Santi RN, Orgill DP. What is
the metabolic response to the burn injury and why it is maladaptive?
Educating burn care professionals world wide (6 screens) 2000
available from URL www Burnsurgery.org.
6. Hart DW, Wolf SE, Herndon DN, Chinkes DL, Lalso Obeng MK, et
al. Energy expenditure and calorie balance after burn increased
feeding leads to fat rather than lean mass accretion.Ann
2002;235(1)152-6.
7. Gianotti L, Nelson JL, Alexander JW, Chalk CL, Pyles T. Post
injury hypermetabolic response and magnitude of translocation:
Prevention by early enteral nutrition. Nutrition 1994;10:225-231.
8. Wang S, Wang S, You Z. Clinical study of the effect of early enteral
feeding on reducing hypermetabolism after severe burns. Zhonghua
Wai Ke Za Zhi 1997:35 (1); 44-47.
9. Frankie D. Anesthesia and intensive care medicine 2003:115.
10. KP Singh et al. Burns 1998;733-738.
11. Nuguyen TT, Gilpin DA, Meyer NA, Herndon DN Current
treatment of severely burned patients. Ann. Surgery 1996:223:14-
25.
12. Wilmore DW, Orcutl TW, Mason AD, Pruitt BA. Alterations in
hypothalamic function following thermal injury. J Trauma
1975:15:697-703.
13. Jeffries M, Vance M .Growth hormone and cortisol secretion in
patients with burn injury. J. Burn care Rehab 1992:13:391-5.
14. Jeevandam M, Ramias L, Shamos R, Schiller W. Decreased growth
hormone levels in the catabolic phase of severe injury. Surgery
1992;111:495-502
15. Cochrane injuries Group Albumin Reviewers Human Albumin
administration in critically ill patients: Systematic review of
randomized controlled trials. Br. Med J.1998;317:235-40.
16. de Gaudio AR. Therapeutic use of albumin. J. Artif. Organs
1995:18:216-24.
17. Sobotka L, Allison SP, Furst P, Meier R, Pertkiewicz M, Soeters
PB, et al Basic in clinical nutrition, 2nd edition Publishing house
Galen: 2000;234-9
18. Le Boucher J, Cynober L. Ornithine and alpha ketoglutarate: the
puzzle Nutrition 1998:14;870-73.
19. Saffle JR, Webke G, Jennings K, Morris SE, Barton RG. Randomized
trial of immune enhancing enteral nutrition in burn patients. J
Trauma 1997:42;793-802.
20. Gottschlich MM, Jenkins M, Warden GD, Boumer T, Havens P
Snook JT. Differential effects of 3 enteral dietary regimes on
selected outcome variables in burn patients. JPEN 1990:14;
225-36.

450
Principles and Practice of Burn Care
Physiotherapy for Burn Patients
33
Sarla Passi
Chapter
INTRODUCTION
Physiotherapy occupies a very important role in the overall
management of burn patients. Irrespective of the extent of
burn injury, most minor or very extensive, a burn patient
needs physiotherapy. A physiotherapist working in the
department of burns has a special understanding of the
magnitude of burns, its systemic consequences, the varied
complications and the knowledge of the healing processes.
He/she can better understand the rehabilitation goals,
modalities of treatment and behavior of the patient and ensure
quicker healing and rehabilitation.
Post burn deformities in children can be very severe as
the bones are still growing and are very soft. The bony
deformities can occur due to contraction of the burn scar.
The importance of physiotherapy is not understood by most
patients and they tend to avoid it because it is time
consuming, painful and requires a lot of hard work both by
patient and physiotherapist.
The treating burn surgeon must emphasize the need for
physiotherapy to the burn patients starting from the initial
stages of treatment to ensure minimization of scars, return
of complete joint mobility, muscle strength and an outcome
of soft and supple scars. Physiotherapy plays a special role
in the management of acute burns as well as the post burn
sequelae. After any surgical procedure under general
anesthesia, the patients require breathing exercises. If the
operated area requires immobilization, the rest of the body
needs to be exercised. The Physical therapy program
involves regular evaluation and supervision followed by
thorough planning of the treatment with documented
progress report to achieve maximum recovery from the
burn injury sustained, in the shortest span of time.
OBJECTIVES OF TREATMENT
The primary goal of physical therapy is to:
1. Make the patient comfortable in proper position,
2. Encourage breathing and coughing to look after
pulmonary health,
3. Prevent contractures by splinting and positioning,
4. Maintain normal range of motion of all joints, whether
overlying skin is burnt or not,
5. Maintain muscle power,
6. Build positive attitude towards treatment, thus
strengthening the confidence of the patient and
7. Modify scars till they become soft and supple.
INITIATING TREATMENT
Physiotherapy starts from the first day. A post burn patient
is in considerable pain; hence the first challenge is to address
the patient’s fear of moving a burnt extremity because of
the anticipated pain. When the patient is in a position to sit,
he should be taught a comfortable way to sit, fully supported
in the beginning and then gradually on his own. If the patient
is ambulatory, he should be encouraged to ambulate till he/
she becomes independent.
STAGES OF THE TREATMENT
Physiotherapy treatment can be classified into following
stages:
a. Acute Treatment, in the Intensive Care Unit. This
comprises of breathing exercises, proper positioning,
supportive movements, splinting and ambulation.
b. Subacute, in the Hospital Ward. This comprises of
positioning, maximising joint mobility and muscle

Physiotherapy for Burn Patients
451
strength, ambulation, looking after spontaneously healing
and skin grafted areas and advising pressure garments
and splints.
c. Follow-up, in the Outpatient Department. This
comprises of ensuring maximum joint range, maximum
muscle strength and return to normal duties, care of
skin grafted and spontaneously healed burnt and donor
sites.
Physiotherapy in Acute Stage
Day 1
If the neck and chest or back are burnt, the patient may
not be able to breathe properly due to pain. The easiest way
to encourage the patient to breathe normally is to ask the
patient to blow as much as possible. In case of children,
blowing balloons may be a good incentive. If a balloon is
not available, make do with a paper bag and make it a game
to be enjoyed. Deep breathing facilitates the expansion of
the chest, which in turn, helps increased oxygen intake (Fig.
33.1).
Before starting any exercises, it is essential to pay
attention to the position of the patient. The head end of the
bed is raised so that patient is upright and properly supported.
A pillow is placed under the knees to make the patient
comfortable, making sure that the diaphragm is not stretched.
Ask the patient to blow as much as possible. In case of
burned axilla the arms should be raised and supported at
90° from the torso. Standing sideways, the therapist can
support the patient’s arms.
On Day 2
If the patient is not severely burned or if the patient is
comfortable and confident, make the patient sit sideways.
High sitting (sitting straight with legs down) with the same
exercises (as above) can follow (Fig. 33.2).
Fig. 33.1: Patient is encouraged to sit and do the breathing
exercises
Fig. 33.2: High sitting posture
On Day 3
The same exercises as on Day 2 continue. The patient can
be asked to stand and take a few steps close to the bed. If
the patient complains of dizziness (which is normal effect
of increased gravitational pull felt on being put in a vertical
posture after prolong duration in the horizontal posture during
the initial stages of treatment), he should be allowed to lie
down immediately. Gradually standing time can be increased.
Day 4 Onwards
The above exercises are increased gradually till patient adjusts
to them and with continued exercises the patient will
ambulate earlier and feel better. If the patient is severely
burned, ambulation may take more time. The exercise
program must be continued regularly. Physiotherapist should
continue with positioning and splinting in acute stage to
prevent contracture later on.
Management of Neck Burns
Burn injuries in the neck are very common in India, since
kitchens in most Indian villages and in poor urban homes
have the cooking stoves on the floor. Working on such a
stove requires the cook to bend in front of the open flame.
In addition, most of these stoves use kerosene to ignite a
fire. The resultant burst of flames has a high probability of

452
Principles and Practice of Burn Care
touching the cook’s loose clothing (‘dupatta’), usually
wrapped around the neck. To make matters worse, these
‘dupattas’ are usually made of synthetic material, causing
even more damage since the material sticks to the neck on
catching fire, causing deep neck burns.
It is critical to pay particular attention to the position of
the neck, since the neck can flex easily. Although a pillow
provides some comfort to the patient, the use of a pillow
must be discouraged as it leads to flexion contracture. The
patient should also be provided with a cervical collar, after
the dressing to prevent flexion of the neck (Figs 33.3 and
33.4).
This may cause the patient to complain of pain in the
cervical region, since extensor muscles get fatigued. The
Physiotherapist must give static exercises of flexion and
lateral rotations to relax the patient and increase strength of
muscles (Figs 33.5A and B).
Management of Chest and Axilla Burns
A patient with neck, axilla and chest burns needs close
attention since the neck and axilla can easily develop flexion
contracture. In the case of axillary burns, however, the
patient’s arm has to be maintained in abduction. A pillow
may be used and the patient must be aware of abduction
even when he is lying on his side (Fig. 33.6).
In chest burns, breathing exercises play a very crucial
role in the complete treatment. The patient tends to avoid
breathing properly due to the pain, as a result of which
chances of chest congestion go up considerably. Patient
should be encouraged to cough to clear the lungs.
Fig. 33.3: Wrong use of the pillow encourages formation of neck
contracture
Fig. 33.4: Cervical collar with dressing
Fig. 33.5A: Neck extension excercises
Fig. 33.5B: Neck flexion excercises
Correct

Physiotherapy for Burn Patients
453
Management of Elbow and Hand Burns
In the case of elbow burn, the elbow tends to go into flexion
contracture very soon. The patient must, therefore, be
provided extension splints. In the case of children, it is
important to handle the elbow carefully as they may get
myositis ossificans. Care should be taken to avoid applying
force during dressing and splinting.
The hand is a highly specialized part of the body.
Treatment of burns of the hands poses a great challenge to
the Plastic Surgeon and the Physiotherapist. The wrist must
be kept in extension with Metacarpophalangeal (MP) joints
in flexion and Interphalangeal (IP) joints in extension and
thumb in opposition (Fig. 33.7A).
After the dressing, a splint must be applied immediately.
The splint should be removed twice daily to allow active
exercises, after which it is applied again, ensuring that there
is sufficient space between the webs and thumb in
opposition. Sometimes, ready-made splints may not fit the
patient well. In such cases, a customised Plaster of Paris
(PoP) splint should be made to ensure that the patient does
not develop any contracture (Fig. 33.7B).
Management of Lower Limb Burns
Lower limb contractures are a very common occurrence.
If both the hips and abdomen are burnt, the patient is likely
to develop hip adduction contracture. This can be very
disabling. The patient may not be able to sit, may walk with
shuffling gait and may find it difficult to climb stairs. For a
patient admitted with such burns, both the legs must be
“abducted” and extended, perineal and hip adduction
exercises continued. In the case of small children, a hip
spica splint may need to be applied. In the lower limb, the
splint is given on the posterior side with knee in extension.
Management of Knee Burns
A patient with knee burns must be kept in supine position
and given a knee extension splint. After quadriceps exercises
twice a day, the splint is firmly tied again. The patient can
be ambulated with knee in extension and may be advised to
use his hip flexors to clear the ground.
Management of Ankle Burns
Ankle flexion contracture is very common. This is because
the inherent strength of the tibialis anterior and pronator
Fig. 33.6: Conforming abduction splint of the shoulder
Fig. 33.7A: Position of hand — Wrist in extension, MP flexion and IP
extension (Thumb in opposition)
Fig. 33.7B: Simple PoP cock-up splint

454
Principles and Practice of Burn Care
Physiotherapy in Later Stages
When a patient is under the supervision of a Physiotherapist
from the very beginning, there are likely to be fewer
complications during the successful treatment. However,
in developing countries, a patient suffering from burns may
reach a burn center very late. By this time, they already
suffer from large raw areas which require skin grafting
and/or contracture(s) have already been formed. In such
cases, Physiotherapy plays a very crucial role. As soon as
patients wounds are completely healed, he/she should be
encouraged to eat and dress himself and take care of his
personal hygiene. The family should be asked to help him
only when the task is impossible. This not only allows
physiotherapy of all joints but also gives a feeling of well-
being to the patient.
The following steps must be taken to determine the
Physiotherapy Program for such a patient:
1. A patient who visits the Physiotherapy Department should
be evaluated for the following:
•
How big is the wound?
•
Is it on a joint?
•
Has the patient developed any contracture?
•
If yes, what is the degree of contracture?
•
Has the wound healed with hypertrophic scars?
If all the wounds have healed by the time the patient
reports to the physiotherapist, he has to evaluate all
the joints for limitation of motion due to scars and
contractures. The severity of limitation is then graded:
a. Acceptable: The motion of the joint is otherwise
normal but limited in the final arc of motion (Fig.
33.9).
b. Functional: There is 50% of normal joint motion
allowing patient to function independently (Fig.
33.10).
c. Severe: The range of motion is less than 50% of
normal, restricting normal function and therefore,
demands reconstructive surgery (Figs 33.11A
and B).
tertius muscles enables the patient to start walking on his
heels. To stop this, anterior (dorsal) ankle splint should be
given. This prevents the contracture and help the patient
develop Heel-Toe gait. In case of posterior burn, the ankle
must be kept in neutral position.
Splinting and exercises must start right from day one or
two (Fig. 33.8). If a burn patient has even a few days of
immobility in the position of comfort, not only will he/she
be fearful and resist any active or passive motion, but
musculoskeletal alterations will also begin to develop.
Fig. 33.8: Krammer wire foot drop splint
Fig. 33.9: Acceptable deformity
Fig. 33.10: Functional deformity

Physiotherapy for Burn Patients
455
by propioceptive neuromuscular facilitation (PNF)
exercises.
To understand the role of physiotherapy in the
improvement of scars, it is important to recognise the
function of skin in the human body:
a. Regulation of body temperature: The body
temperature is regulated by an increase or decrease
in perspiration, superficial blood flow or both;
b. Protection: The skin acts as a barrier to protect the
body against invasion of micro-organisms, ultraviolet
radiation, abrasions, chemicals and dehydration.
c. Sensation: Multiple sensory cells within the skin
detect pain, temperature and touch.
d. Excretion: Sweat and water are excreted and heat is
dissipated through the skin.
e. Immunity: Normal, periodic loss of epidermal cells
removes micro-organisms from the body surface.
Immunity cells in the skin transport antigens from
outside the body to the antibody cells of the immune
system.
f. Blood reservoir: Large volumes of blood can be
shunted from the skin to the central organs or
muscles when needed.
g. Vitamin D synthesis: Modified cholesterol molecules
are converted to vitamin D when exposed to
ultraviolet radiations.
Treatment of Wounds/Scars/Grafts
in Physiotherapy
Since the skin covers the musculoskeletal system, any injury
to the skin directly affects the movement of that particular
part of the body. As a result, the patient tends to keep that
part in a comfortable position and not move it in an attempt
to avoid pain. Such a comfortable position is very likely to
cause contracture and disuse-atrophy. In this stage, as the
wound heals, the scars form. The physiotherapist plays a
critical role in the improvement of the wound. In the previous
chapters, the treatment of wounds with dressing and
medication has been discussed in detail. Physiotherapy can
help the patient by reducing the pain using ultrasound and
ultraviolet therapy that helps in healing of the wounds.
Ultrasonic treatment is given around the wound with Pulse
duration of 1.5 cm/sec for duration of 5-10 minutes,
depending on the area (Fig. 33.12).
Ultraviolet treatment is given by first cleaning the wound
with saline. The ultraviolet lamp should be fixed at a distance
of 18-20 inches. The lamp should be covered with a cloth
so that the other parts of the patient’s body are not exposed
Fig. 33.11A: Severe deformity restricting hand and wrist
movements and function
Fig. 33.11B: Severe deformity restricting function of multiple areas
2. After the evaluation, the line of treatment should be
determined by the physiotherapist. This includes
decisions such as:
•
What should be the exercise program?
•
What splint should be given?
•
How much can the patient achieve?
3. In case of small hypertrophic scars, they may improve
with ultrasonic treatment, use of pressure garments and
silicone gel.
4. If there is nerve injury, the patient must be evaluated
with strength duration curve and reaction of
degeneration. A muscle chart is prepared and stimulation
given to the patient accordingly. This may be followed

456
Principles and Practice of Burn Care
to the ultraviolet rays. The patient and the therapist must
use dark glasses to avoid ultraviolet rays. The treatment is
given for duration of 15-20 minutes followed by usual
dressing. It gives good results and the patient is likely to
cooperate more willingly during the dressings.
The ultraviolet lamp should be placed in the dressing
room so that the patient is not required to move
unnecessarily. It is recommended that the therapist goes to
the dressing room to give the ultraviolet treatment so that
she/he can correct the position of the particular body part,
give exercises and tie the splint after the dressing.
Management of Grafted Neck Burn Wounds
The most common burn injuries to the neck are in the anterior
region. In acute cases alone, the patient must be given
cervical collar (hard) during the dressing so that the patient
does not develop a flexion contracture. The position of the
neck must be maintained till the wound healing is completed.
After grafting of neck wounds, the patient’s neck is kept in
hyperextension to keep the graft in the stretched position
(Fig. 33.13).
The exercises recommended are the same as those
recommended in the acute stage.
The exercises are detailed as follows:
i. Ask the patient to press the head down towards the
bed.
ii. No head movement must be allowed as these are only
muscle-strengthening exercises.
iii. The same exercise should be repeated sideways. This
makes the patient comfortable and gives a feeling of
well-being.
iv. All the movement of shoulders and elbows and hands
are done,
v. This is followed by leg movements to ambulate the
patient as early as possible,
vi. It is very important to teach the patient how to get off
the bed without disturbing the neck. The patient must
first sit up in bed, then put the legs down and stand
up. During this movement, the patient may feel giddy,
nauseous for a few days but this soon normalises
with the neck exercises.
vii. When the dressing of the grafted part and the donor
part is removed, post grafting exercises and massage
should be started.
a. Patient should be put in supine position with neck
in extension.
b. Massage with coconut oil or some soft lubricant
should be done.
c. Efflurage massage followed by thumb kneading for
15 to 20 minutes. The patient should be taught how
to massage so that he can look after the grafted
part himself.
d. Exercises of the neck should be followed by
massage to keep the grafted skin soft and supple in
the right position. Silicon gel may be applied after
which pressure garment may be used to avoid
hypertrophy of scars (Fig. 33.14).
Even if the patient complains of discomfort due to warm
climate, the pressure garment and collar must be used and
its importance explained to the patient.
In children four-post collar (Figs 33.15A and B) is
advisable as they are growing and such a collar can be
Fig. 33.12: Ultrasonic treatment in progress
Fig. 33.13: Simple cervical collar

Physiotherapy for Burn Patients
457
adjusted easily. It is crucial to ensure that the patient does
not develop an ulcer because of an ill-fitting collar or pressure
garment. When the pressure garment or collar is worn for
the first time, the patient should be asked to remove it often
and air the body part till he gets used to it.
The collar must be well-fitting and not too tight. The
collar must be worn for six to ten months.
Massage should be continued for a year and must always
be done with clean hands and nails. The use of a pillow
must be strictly avoided for a period of one year.
Management of Grafted Axillary Burn Wounds
If the axilla has a deep burn, skin grafting is required. The
graft has to be taken care of in the same manner as the
neck (given above). Abduction splint is given to maintain
the graft and prevent graft contraction (Fig. 33.16).
After the operation breathing exercises are given. The
patient should be ambulated and he can initially use the other
arm to support the operated arm. Elbow, wrist and hand
exercises must also be done (Fig. 33.17). The patient must
be given scapular adduction and elevation exercises. It is
crucial that the attention be paid to the patient’s posture so
that he does not develop scoliosis. In children this is
particularly critical as lack of care may lead to permanent
scoliosis. Once the bandage is removed and the graft is in
place, exercises of the shoulder must be started immediately
(Fig. 33.18). This is crucial as the shoulder may become
stiff due to immobilization in the cast. In children,
mobilization of the shoulder takes place relatively early as
compared to adults who may suffer from frozen shoulder
Fig. 33.14: Application of silicon gel sheet on hypertrophic scar
Figs 33.15A and B: Adjustable four-post collar
Fig. 33.16: Abduction splint
A
B

458
Principles and Practice of Burn Care
straight position and an anterior splint will be provided.
The patient should be given shoulder exercises with
support along with hand exercises. As soon as the graft
is taken up and the bandages removed, massage is
initiated. Elbow exercises within the tolerance level of
pain of the patient may also be started. Passive
movements of the elbow are not indicated as the chances
of myositis ossificans are greater. After massage and
exercises, the patient should be given pressure garment
and splints (Fig. 33.20).
2. Elbow grafting on posterior surface: If grafting is done
on posterior side, the elbow is kept slightly in flexion.
Splint support is not required. A regular schedule of
or periarthritis (Figs 33.19A and B). In such cases the patient
may be given Interferential Therapy (IFT) to reduce the
pain followed by exercises. If the pain is local, ultrasound
therapy may be combined with the exercises for speedy
recovery. The patient should also be taught home-based
exercises to get effective results.
Management of Grafted Elbow Burn Wounds
Grafting on elbow wounds may be of three types:
1. Elbow grafting on anterior surface: If the grafting is
done only on the anterior surface, the elbow will be in a
Fig. 33.18: Shoulder exercises in children after
correction in axillary contracture
Fig. 33.17: Axillary contracture
Fig. 33.19A: Shoulder exercises
Fig. 33.19B: Equipment for physiotherapy
of shoulder joint

Physiotherapy for Burn Patients
459
massage, exercises and use of pressure garment after
graft take are adequate to help the patient.
3. Elbow grafting circumferentially: In case of
circumferential burns, the splint used is the same as in
the case of anterior burns. It is important to ensure that
exercises are given with great care as these may be
very painful for the patient. This is also crucial to ensure
that the graft from the extensor side is not stretched too
much in extreme flexion.
It is recommended that active exercises of the elbow
are taught with flexion, extension, supination and pronation
in the sitting position, with the humerus well-supported and
with a dumbbell in hand.
Management of Grafted Wrist Burn Wounds
Wrist burns can result in four types of contracture if not
grafted in time:
•
Wrist flexion
•
Wrist extension
•
Ulnar deviation
•
Radial deviation
In the case of grafting on the flexor surface of wrist, the
postoperative hand should be elevated to reduce edema.
After the graft take, exercises are started and only extension
must be encouraged for the initial 2-3 days followed by
finger flexions. Cock up splint is given to maintain wrist
extension.
After the dressing is removed, massage should be done
using coconut oil and the patient should be encouraged to
use the hand. This is crucial to avoid graft contracture and
facilitate maximum functioning of the hand. The use of a
splint helps to keep the wrist in extension.
The patient must wear the pressure garment for 6-12
months. In case the patient desires to use the injured hand
for household work such as cooking, the pressure garment
may be removed for that period of time and put in use again
immediately after the task is over. This is essential to keep
the graft in the correct position and avoid any hypertrophy
of the scar.
Fig. 33.20: Extension splint at elbow
Fig. 33.21: Wrist and elbow contracture released
When a graft is applied on extensor surface of wrist the
hand must be kept in a straight position and elevated (Fig.
33.21). Movement of the fingers must be encouraged after
graft take. When the dressing is removed and the graft has
healed well, the massage and finger exercises can be initiated.
Along with wrist movement given by the therapist, the patient
must be encouraged to use the hand for normal functions.
A pressure garment and splint must be used at night. A
considerable amount of wrist flexion must be given to ensure
that the patient does not get wrist extension contracture.
If the graft is applied on the ulnar side, the hand must
be stretched on the radial side to keep the graft stretched.
Similarly, if the graft is on the radial side, the hand should
be stretched on the ulnar side. In both cases hand
movements must be continued along with the use of splints
and pressure garments for a prolonged period of time.
Management of Hand Burns
Hands are very prone to burns as they are instinctively used
to protect the body from any physical harm. Similarly hands
are the most used parts of the body for all tasks. As a result,

460
Principles and Practice of Burn Care
burn injuries of the hands leave the patient extremely
dependent for even routine activities. Although they are
relatively small body parts, hands play a crucial role in major
body functions. Hands comprise of small inter-articulating
bones, muscles, blood vessels and nerves covered with skin.
To cater to different functions, the hand is covered with
two different types of skin: Dorsal and Palmar. The Palmar
skin is very thick and can handle rough objects whereas the
dorsal skin is thin and supple.
An understanding of the structure of the hand and its
parts is crucial in determining a program for its rehabilitation.
The hand complex consists of five digits each of which has
a metacarpal and a metacarpophalangeal (MCP) joint. Each
finger has two interphalangeal (IP) joints, while the thumb
has only one. There are 19 bones, distal to the carpals and
19 joints that together make up the hand complex.
Articulations in hand are of three types, viz.,
carpometacarpal, metacarpophalangeal and interphalangeal
joints. The muscles of the hand are classified as extrinsic
and intrinsic muscles. These muscles join together to perform
the function of the fingers and the wrist.
Extensors of forearm comprise of:
•
Brachioradialis;
•
Extensor carpi radialis longus
•
Extensor carpi radialis brevis
•
Extensor indices,
•
Extensor digitorum communis,
•
Extensor digiti minimi,
•
Extensor carpi ulnaris
•
Anconeus.
Flexors of the forearm and hand comprise of:
•
Pronator teres
•
Flexor carpi radialis
•
Palmaris longus
•
Flexor carpi ulnaris
•
Flexor digitorum profundus
•
Sublimis
Intrinsic muscles of hand are:
•
Thenar group
•
Hypothenar group
•
Lumbricals
•
Interossei
The wrist performs the function of flexion, extension,
ulnar and radial deviation and circumduction. The thenar
group of muscles perform the thumb functions; hypothenar
group of muscles perform the function of the little finger
while the interossei and lumbricals perform abduction and
adduction of the fingers. These combine with extensor
tendons for finger extension.
All the above muscles are responsible for different
functions for the hand. They are attached to small bones in
the hand. The hand also consists of some important soft
tissues that help in different hand functions. For instance,
the volar plate is a multi-layered structure consisting of
fibrocartilage, responsible for thickening of the inside of
the joint capsule.
The joint capsule, superficially located transverse
metacarpal ligament and transverse fibers blend with original
longitudinal fibers of the MCP joint capsule to get co-
ordinated action of the MCP joint. Flexible attachment of
the plate to the phalanx permits the plate to glide proximally
along the volar surface of the metacarpal head without
restricting motion. This fibrocartilage mechanism also
prevents pinching of the long flexor tendons during flexion.
In the case of extension, the plate adds to the amount of
surface in contact with the large metacarpal head. The plate
also helps to restrict the hyperextension that is permitted by
the loose capsule.
The position of comfort is always preferred by the patient
and this position predisposes to contracture formation, e.g.
in the hand, the typical post burn claw hand results from
keeping the hand in position of rest, i.e. wrist flexed, MCP
joints extended and IP joints flexed. It is important to avoid
this position while dressing the areas. Elevation of burnt
hands is also essential to reduce edema. Active exercises
are encouraged by the use of open method of treatment. In
this, the hand is smeared with silver sulfadiazine cream and
enclosed in a polythene bag in which movements of all the
joints are allowed and also easily monitored.
In case of hand burns, the following deformities are
possible:
•
Typical claw hand
•
Boutonnière deformity
•
Swan neck deformity
•
Subluxation of MP joint
•
Mallet finger
Typical claw hand is characterized by MCP joint
extension, IP joint flexion and thumb adduction (Fig.
33.22).This deformity results in a loss of grip and pinch
resulting in nearly 60% loss of hand function. This
contracture, can be avoided if splinting is done from the
very beginning followed by active exercises. It is critical
that no passive movement is given in acute stage to avoid
rupture of any soft tissue.

Physiotherapy for Burn Patients
461
Different types of splint may be used to avoid this
deformity (Figs 33.23 to 33.24B). A Simple Static Splint
provides flexion at the MP joint and extension at the IP
Joint. The thumb is maintained in abduction. Once the
grafting of hand is completed, the patient may be given a
pressure garment and a splint to maintain the correct position
of the hand. Exercises must be done 2-3 times a day (Fig.
33.25). Once the area has healed, the patient must be
encouraged to use the hand ensuring no further injury. If a
child has received this treatment, he must be encouraged to
attend school and perform his daily tasks himself.
Boutonnière Deformity
A deformity of this nature involves a stretch or tear of the
central extensor slip, as a result of which the lateral bands
migrate volarly and flex the proximal IP Joints (Fig. 33.26).
The distal phalanx also extends due to stretching of the
lateral bands. The net result is that the intrinsic and extensors
migrate proximally, resulting in this particular deformity. A
mild deformity does not affect the functioning of the hand
but if it is severe, the patient is unable to tighten the fist and
also loses pinch movement.
It is recommended that finger splints be given at an
early stage to avoid stretching of the lateral slip. The required
splints, for individual fingers, are easily available
commercially. The same splint can be used as either static
or functional splint. However, if all the fingers are involved,
a simple Cock-up Splint is recommended.
Swan Neck Deformity
The contracture of the intrinsic muscles causes flexion at
the MP Joint, hyperextension at the proximal IP Joint and
flexion at the Distal IP Joint. This deformity can also be
avoided by the early use of a splint and correct timely
exercises. If contracture has already taken place and the
capsule is damaged, it is crucial that surgery is followed by
splinting and exercises (Fig. 33.27).
Fig. 33.22: Typical claw hand
Fig. 33.23: Cock-up splint
Fig. 33.24A: Short Cock-up splint (Functional cock-up splint)
Fig. 33.24B: Same splint–Palmar view

462
Principles and Practice of Burn Care
Such a deformity may involve the tearing of the capsule
or herniation of the head of the metacarpal or the base of
the phalanx. Extension of the MP Joint may affect the grip
of the hand (Fig. 33.28).
The rehabilitation of hand consists of splinting the MCP
joint in flexion using a static splint initially, followed by the
use of a functional splint for a few weeks accompanied by
massage and exercises. Active exercises are recommended
and the patient must be encouraged to start performing his
normal tasks as early as possible.
Mallet Finger
This is caused by a rupture or tear of the extensor tendon,
proximal to the insertion of the lateral band on the proximal
aspect of the distal phalanx. The resultant damage allows
the horizontal proximal pull of the extensor tendon and flexor
digitorum profundus tendons, causing a loss of extension
of distal phalanx (Fig. 33.29).
This deformity can be a deterrent to minute hand
functions. It may be corrected surgically followed by
splinting and exercises.
Functional splints for different hand and finger
deformities are available in different sizes (Figs 33.30A
to H).
Management of Burns of Lower Extremities
There are various deformities which can occur following
burns of lower extremities.
•
Flexion contracture of hip
•
Hip adduction and perineal contracture
•
Flexion contracture of knee
Fig. 33.26: Typical boutennière deformity. Arrows 1-6 showing the
direction in which the force on bones and joints acts to cause the
deformity
Fig. 33.25: Hand exercises after correction
Fig. 33.27: Typical swan neck deformity subluxation of MP joint. Arrows
showing the direction in which bones and joints get deformed
Fig. 33.28: Subluxation of MP joint
Fig. 33.29: Mallet finger. Arrows showing the direction in which the
force on bones and joints acts to cause the deformity

Physiotherapy for Burn Patients
463
Figs 33.30A to H: (A) Individual Finger Splints (B to G) Individual finger splints (Readymade
Splints available). (H) Spring for improving grip
A
B
C
D
E
F
G
H

464
Principles and Practice of Burn Care
•
Foot drop
•
Calcaneal deformity
•
Varus deformity
•
Valgus deformity
•
Flexion contracture of hip—Comfortable position is the
key to hip flexion contracture (Fig. 33.31). Whenever
there is abdominal burn or hip burn, patient tries to flex
the knee and hip to make himself comfortable. To avoid
this contracture, there are two positions.
a. Keep a hard pillow under the pelvis and knee extension
splint bilaterally.
b. Keep the patient in prone position. In case of children,
hip spica (Figs 33.32 and 33.33)with knee extension
can be given till the wound is healed and graft is mature.
Perineal contracture can be avoided by keeping the hips
abducted.
Flexion contracture of knee (Figs 33.34 and 33.35) is a
very common contracture because it is a very comfortable
position for sleeping and sitting but is very bad for
ambulation. The patient becomes handicapped with knee
flexion contracture. If not corrected, it can spoil the spinal
posture and patient may develop kyphosis.
In case of a child with unilateral knee flexion contracture,
patient may develop contracture on normal side to
compensate shortening of affected leg due to knee flexion
contracture and may develop scoliosis. This is to be avoided.
If grafting is done, the patient should be made to walk with
the support of crutches for a few days and then supported
with a splint. Patient must be given knee exercises to avoid
any weakening of muscles (Fig. 33.36). Patient should be
given gait training after the exercises since many times gait
is affected due to prolonged knee flexion contracture.
Splinting and grafting—When knee flexion is very severe
and complete release is not possible, serial knee extension
splint is given. It should be extended after every second
day if it is not painful. In case of loss of quadriceps muscles,
knee support should be given for ambulation and in some
cases by calipers (Fig. 33.37).
Foot Drop or Tight Tendo Achilles (TA)
Foot drop can occur if tibialis anterior is burnt or there is a
nerve injury along with burn. Patient must be given foot
drop splint to avoid TA tightness. Sometimes the nerve injury
is non-recoverable and the patient has a permanent foot
drop. In this case caliper with a below knee posterior stop
at ankle is given. This enables the patient to walk easily
without lifting the hip to clear the ground. If a caliper is not
Fig. 33.31: Patient with hip flexion contracture
Fig. 33.32: Hip spica
Fig. 33.33: Hip correction after use of hip spica

Physiotherapy for Burn Patients
465
Fig. 33.34: Bilateral knee flexion contracture
Fig. 33.35: After serial splintage, both knees are
corrected and patient is made to ambulate with a walker
Fig. 33.36: Quadriceps knee exercises after the correction
given, the patient will walk raising the hip and may develop
the following problems:
•
Backache
•
Wrong gait
•
TA tightness
•
Inability to turn
•
Early exhaustion
Calcaneal Deformity
Calcaneal deformity occurs when tendo Achilles or
gastrocnemius is burnt and not repaired. Patient will not
have heel to toe gait and will develop hyperextension at
Fig. 33.37: Patient is made to ambulate with above-knee caliper
knee joint. To avoid this, the patient should be given a caliper
even after repair as he would need support to heal the
repaired tendon. It should be a below knee caliper with
anterior stop bar to avoid powerful foot dorsiflexion. Heel-
pad should be given to get proper heel to toe gait. Once the
tendon is repaired properly, the patient should be given
exercises to strengthen TA and proper gait training.
Valgus Deformity
Valgus occurs when there is tightness of Peronei and tibialis
anterior muscles due to burn. Here tendon repair is required
followed by a caliper to ambulate the patient and avoid

466
Principles and Practice of Burn Care
recurrence of valgus deformity. If deformity occurs again,
then for one year the patient is given a caliper with a below
knee inside t-strap to avoid valgus position.
Varus Deformity
If peronei muscles are lost due to deep burns, flexors and
tibialis anterior are very strong muscles and foot goes in
varus position. To avoid this, repair may be needed and
then the patient has to be given exercises to strengthen
peronei and below knee caliper for some time is indicated.
TYPES OF SPLINTS
After the initial resuscitative procedures brings the patient
out of the acute phase, all efforts have to be made to prevent
burn wound contractures in order to minimize deformities
later on if no action is taken in the initial stages. The
fabrication and application of splints is of utmost importance.
Splints maintain the joints in anti-deformity position and
each splint should be ideally custom fitted for every individual
patient.
There are 3 kinds of splints used in burn patients–Static,
dynamic and semi-dynamic.
A static splint keeps the part in a particular position and
does not allow movement of that part.
Dynamic splint supports that part but allows movement.
Semi-dynamic splint supports the part and allows very little
movement. It all depends on the condition of the patient.
Splint Selection
Nowadays, readymade splints are available in all sizes; yet
sometimes, tailor made splint may be needed. Splints should
be light, well padded, easy to wear and easily removable.
Materials used in splints should not be toxic, should be easily
available and economical. The material should be non-
absorbent to avoid bacterial growth. Expediency is essential
in the fabrication of splints. Esthetics should play a
secondary role. With no other treatment, there is a higher
occurrence of deformity that may ultimately require many
surgical procedures and an extended period of rehabilitation.
Thermoplastics are easy to use and make a static splint.
It can be used for ‘serial’ splintage as it can be reused after
putting it in hot water. It is advisable to cut different types
of cock-up splints and knee extension splints so that it does
not take much time to create a splint.
Dynamic splints are readily available and can be obtained
for all body parts – fingers to axilla and foot to knee. They
are very easy to use and do not restrict joint ranges or
muscle power.
Pressure Garments
After the wounds have healed, pressure garments help to
reduce thickness of scars and flatten irregularly thickened
areas thus preventing hypertrophic scars and keloids.
Though all scars improve with time, the pressure garments
help to accelerate the process by early maturation of scars.
Pressure garments can be readymade or tailor-made to
suit specific needs. Readymade pressure garments can be
used for parts like extremities, chin and wrist but in case of
face, chest and perineum only tailor-made garments are
effective( Figs 33.38 to 33.40).
In case of lower extremity, after the grafting, a patient,
if made to stand straightway, will feel pin pricks and his
graft will develop blistering because of venous congestion.
To avoid this, the patient should be taught dependency
exercises and made to wear pressure garments.
Fig. 33.38: Custom made pressure garment for full body
(Courtesy: Technomed Pvt. Ltd.)
Fig. 33.39: Pressure garment for face
(Courtesy: Technomed Pvt. Ltd.)

Physiotherapy for Burn Patients
467
Dependency Exercise
The patient should be made to do dorsi flexion and planter
flexion with high sitting and then patient should be given
quadriceps exercises and made to stand and walk for one
minute. Gradually time duration should be increased and
within a few days, the patient will feel normal.
Duration of Use
Pressure garments should be used for 6 months to a year.
Initially, the patient must use pressure garments for 22 hours
with only minimum time for personal hygiene and exercises.
After 6 months the patient should use the garments only at
night. This will help keep the graft in the right position.
Quality and Maintenance
The material used for pressure garments should be skin
friendly (non-allergic), breathable (porous), equally
stretchable on all sides, should be tested for transfer of
pressure on skin and should be constructed according to
venous pressure gradient. It should be certified as a medical
device by an independent authority of the respective country
like CE or FDA approved.
The garments should be cleaned everyday with soap
and cold water. They should not be dried in the sun. Pressure
garments should be well fitting and easy to remove. They
should have breathing holes.
General Physiotherapy
Apart from providing care to prevent stiff joints, a
physiotherapist needs to ensure that the chances of chest
Fig. 33.40: Tailor made whole body pressure garment in a child
complications, bed sores and deep vein thrombosis in these
chronic bed ridden patients especially the elderly age groups
are minimized. For this chest physiotherapy and postural
drainage, spirometer exercises need to be administered to
the patient daily. To prevent deep vein thrombosis, the patient
should be ambulated as soon as possible or if patient is
unable to walk, he/she should be made to sit and move his/
her limbs.
For postural drainage, either rotating beds (Stryker
frames) are used or it is done manually by the nursing staff.
Air mattresses or water beds should be used to prevent bed
sores with 1-2 hourly change of posture.
Deep breathing exercises should also be encouraged for
proper expansion of lungs.
SUMMARY
Intensive physiotherapy of burned patient should begin from
the first post burn day and continued not only till the patient’s
wounds heal but also beyond that till full function of all
joints is restored. The treatment program should include
daily evaluation, supervision, repeated exercises and splintage
to achieve the best possible results. The improvement in
joint movement and muscle strength and prevention of
deformities by physical therapy and rehabilitation will help
the patient to become functionally independent.
BIBLIOGRAPHY
1. Barlett RH, et al. Rehabilitation following burn injury. Surg Clin
North Am 1978;58:1249-62.
2. Bennett GB et al: Serial casting: a method for treating burn
contractures. J Burn Care Rehabil 1989;10:543-5.
3. Evans EB, Larson DL, Yates S. Preservation and restoration of
joint function in patient with severe burns. JAMA 1968;204:
843-8.
4. Fess EE, Philips CA. Hand splinting, principles and methods, ed 2.
CV Mosby, St. Louis, 1987.
5. Hanson NN. Burns in children. In DiGregorio VR (Ed):
Rehabilitation of the burn patient .Churchill Livingstone, New
York, 1984:131-50.
6. Helm PA, et al. Burn injury: Rehabilitation management in 1982.
Arch Phys Med Rehabil Forum 1985;4:1-4.
7. Khalili AA, Betts HB, Stone NH. Rehabilitation medicine in the
prevention and management of burn deformities; Organisation and
techniques. In stone, NH (Ed): Profiles of Burn management
.Industrial Medicine Publishing Company, Miami, 1969:48.
8. Nothdurft D, Smith PS, Lemaster JE. Exercise and treatment
modalities. In Rehabilitation of burns. Williams and Wilkins,
Baltimore, 1984:96-147.
9. Stachowski M. Kondela-Cebulski P. Physical therapist in burn care.
Phys Ther 1983;63:1091-95.
10. Wright PC. Fundamentals of acute burn care and physical therapy
management. Phys Ther 1984;64:1217-31.

468
Principles and Practice of Burn Care
Post Burn Sequelae and
their Management
34
Arun Goel
Chapter
A severe burn injury is the most devastating injury a person
can sustain and yet hope to survive! These injuries constitute
the second commonest cause of all trauma-related deaths
in the developing as well as the developed countries. Over
the last sixty years, great advances have been made in the
field of burns at basic as well as applied level. The
pathophysiology of burn injury has been understood at
cellular as well as molecular level in great detail. Treatment
methods have been devised to counter and reverse these
changes. Burns are now being treated scientifically in a well
standardized manner. The mortality rates and the morbidity
from burns have diminished greatly so much so that a mere
survival of an extensively burnt patient (say, 65-70% Total
Body Surface Area (TBSA)) is no longer considered a great
outcome. As is true for any other life threatening injury,
survival is the immediate concern for the burn patient, his/
her relatives and the treating clinician. Actually, it is the
degree of restoration to pre-burn level and 'return to society'
which is more important. Burn survival statistics can indeed
be misleading! Unfortunately, the tremendous advancements
in the field of burns have not benefitted a very large majority
of burn victims in India and other developing/under-
developed countries. Post burn sequelae resulting in
disfigurement with grotesque appearance and deformities
with crippling contractures/amputations continues to be a
great challenge to the modern burn surgeons in their attempt
to restore the burnt patient to pre-injury status (Figs 34.1A
to D).
As recently as 1986, Brown and Barot1 wrote, "The
ultimate goal in the treatment of burns is the establishment
of a closed wound with restoration of the intact cutaneous
barrier protecting the patient from his or her environment."
Figs 34.1A and B: Front and lateral view of a 28-year-old female with
extensive post thermal burn scars, severe and multiple contractures
of neck, axillae, wrists and hands. Also note the kyphotic posture and
loss of right nipple-areola complex
A
B

Post Burn Sequelae and their Management
469
The present author would like to replace the word "ultimate"
with "immediate". Unfortunately, such a healed burn patient
may be left with one or more of the various sequelae in
different permutations and combinations. These post burn
sequelae have varying degrees of functional and aesthetic
components. The actual prevalence of these disabling
conditions in general population can never be gauzed
accurately, especially in a vast country like ours. However,
it must be inversely proportional to the standards of initial
treatment with patients receiving best of care having
minimum number and severity of these sequelae.
For descriptive purposes, the various post burn sequelae
have been considered under following headings. An individual
burn patient may have any number of them in varying
severity. Surgical reconstruction2-5 of these sequelae requires
the knowledge and expertise of the full spectrum of a plastic
surgeon's armamentarium from local excision, serial
excisions, tissue expansion, skin grafts, local flaps, regional
flaps, free flaps and prefabricated flaps.
1. Post burn scars,
2. Post burn contractures,
3. Post burn losses,
4. Chronic unhealed areas,
5. Bone and joint deformities,
6. Development of malignancy,
7. Miscellaneous and
8. Psychological disorders.
POST BURN SCARS6-10
Post burn scars are inevitable even with the best of treatment.
This is because they depend upon the depth of burn injury.
Healing of the burnt skin is a complex process where nature
tries to close a wound by deposition of collagen and re-
epithelialization to restore the continuity of the skin. In
superficial dermal burns which heal in less than 14 days,
the healing may be so perfect as to resemble the normal
skin and become indistinguishable from the surrounding
unburnt skin. All other deeper burn injuries lead to healed
"areas" which are clearly different from the surrounding
unburnt skin with respect to their color, texture, dullness/
shininess, stretch ability, hair pattern, thickness etc. even
when the healing had proceeded "normally" (Figs 34.2A
and B). In these cases and in all other cases where healing
has not proceeded normally due to one or more of the various
factors affecting wound healing adversely, the final
appearance of the healed burnt areas is definitely different
from the surrounding unburnt skin.
It must be remembered that the term "scar" has a
different connotation for the plastic surgeon and the patient.
The appearance of even the best skin grafted areas and the
perfectly healed donor sites of these grafts is also a "scar"
by the patient's definition of a scar.
The only way to erase the post-burn scars completely
is to prevent the burn injury itself. 'An ounce of prevention
is better than a pound of cure' is no better exemplified than
by the burn injury. Once burn injury has occurred, the scars
can only be minimized and not prevented or removed
completely by appropriate patient and wound management
in the acute phase including first aid and various physical
Fig. 34.1C: A 16-year-old male with post electric contact burns bilateral
hand deformity with loss of digits and flexor tendons. Distant flap
covers done to perform reconstructive surgery
Fig. 34.1D: Grotesque deformity and loss of function of right hand
in a 30-year-old male

470
Principles and Practice of Burn Care
therapy measures instituted and religiously followed after
the burn wound has healed completely till the complete
maturation of the scar.
Bringing down the temperature of the skin to normal
body temperature in thermal burns as soon as possible by
pouring water minimizes the depth of burn injury. Similarly,
depth in chemical burns can also be minimized by diluting
the chemical thoroughly at the earliest (by water, in general).
Radiation burn injury to skin in cancer patients has been
minimized by improved technology.
Immediate correction of hypovolemic shock and
hypoxia, not only benefits the patient as a whole but also
allows for adequate perfusion of burnt tissues, especially in
the zone of stasis.11 The desiccation of the burn wound,
increased viscosity of the blood and hypoxia of the patient
all lead to death of compromised tissues which could have
survived if appropriate therapeutic measures were instituted
promptly. Along with infection, they can convert a burn
wound into a deeper injury leading to more scarring. In
addition, trauma to regenerating neoepithelium must be
prevented by delicate handling of tissues and use of non-
stick paraffin gauge and antimicrobial ointments/creams and
moist dressings.
It must be noted that for a given depth of burn, the
scars formed are not only different in different parts of the
body but also different individuals show different outcomes
for a given site and depth.
Again, for purely descriptive purposes, the completely
healed burn patients may be divided into two categories
depending on the time of their presentation to the specialist
burn surgeon:
a. The patient is being treated by the burn surgeon from
the acute stage and/or the scars are immature, and
b. The scars have already matured at the time of presentation
to the burn specialist.
When the scars are immature (Figs 34.3A to C, 34.9A
and B, 34.14A to E), their maturation can be altered favorably
by using a number of physical therapeutic measures. These
scars must not be exposed to sunlight till their color returns
to normal or they have matured. The exposure to sunlight
leads to hyper pigmentation of the scars and recently applied
grafts. This is extremely difficult to treat. The exposure
can be prevented by coverage with clothes, avoidance of
outdoor activities, use of caps, pressure garments and sun
screen lotions with SPF (Sun Protection Factor) of at least
20-25. The patients must be fore-warned on the use of
various proprietary creams containing steroids for itching
which is a common complaint in healing and recently healed
burns. This is because steroids are photo-sensitizers leading
to hyperpigmentation. When the scars are accompanied by
contractures, deformities, etc. surgical interventions are
planned to take care of all the problems together as detailed
later.
When the scars are mature, soft and supple without any
contracture, deformities etc. physical therapy measures
cannot alter their appearance (Figs 34.2A and B). These
patients need treatment purely to improve the esthetic
appearance and regain the self-confidence. These are the
patients who need the full spectrum of a plastic surgeons'
armamentarium (Figs 34.4A to D, 34.25A to 34.27E and
Figs 34.2A and B: Well healed post burn scars on face. Note the
difference in color, texture and shininess. No deformity or functional
deficit. Only esthetic considerations.
A
B

Post Burn Sequelae and their Management
471
34.29A to E). Last but not the least, they need psycho
therapy to boost their morale. Most commonly the exposed
areas like head and neck, upper limbs and feet are treated.
It must be remembered that improvement should be seen
in totality and not in isolation. It is of no use making the
upper lip look like normal while the lower lip or forehead is
'ugly'.
The post burn scars may be atrophic, hypertrophic/
keloid, hypo/hyperpigmented and stable or unstable. The
atrophic scars need intervention because they may
breakdown with minimal trauma especially when present
over areas of stress, e.g. joints, scalp, subcutaneous bones
etc. and become unstable. When present over non-stress
areas they are unesthetic. The atrophic scars need excision
and cover with split skin grafts.
The deep dermal burn injuries and the donor sites of
thick split skin grafts, both of which involve the reticular
Figs 34.3A and B: A 45-year man with healed homicidal acid burn
injury with ectropion of eyelids, hazy corneas and immature facial
scars
Fig. 34.3C: Appearance after spontaneous maturation of scars by
physical therapy. The only operative intervention done is release and
grafting of eyelids ectropion. Also note the spontaneous clearing of
corneas after restoration of eyelid function
A
B
Figs 34.4A and B: Young girl with extensive post burn scars
on whole of face
Figs 34.4C and D: Surgical correction by excision and cover with
intermediate thickness split skin grafts from thigh on to cheeks, forehead
and nose. Note good color and texture match on the face and excellent
contour of the resurfaced nose. Patient opted for use of eyebrow
pencil over surgical reconstruction of partial loss of eyebrows
A
B
D
C

472
Principles and Practice of Burn Care
layer of dermis, usually heal by hypertrophic scar formation.
These are hyperemic, red to deep purple in color, raised,
gradually increasing in thickness, firm to hard in consistency
and remain confined to the limits of the original burn injury.
These lesions are itchy and some patients may even complain
of pain or both. There is an over-abundant deposition of
collagen during the proliferative phase of wound healing.
The natural history of these scars is of spontaneous
resolution with diminishing redness, thickness and itching
over a period of 9-18 months when they are termed as
mature. A number of factors can influence the severity and
time period of maturation. Age of patient, anatomical site
and depth of burn, presence of continued infection especially
sinuses due to retained hair follicles, associated repeated
tension due to joint movements are some of the important
factors apart from individual genetic predisposition. The
prevention and treatment of hypertrophic scars is discussed
along with post burn contractures later.
A number of patients have the chief complaint of hypo
or depigmented scars.12 These vitiligo patches are very
unsightly and are a taboo in our society. It may not be
possible to treat all of them if they are extensive. However,
in areas which cannot be covered by clothes like face, neck,
hands and feet, treatment has to be done. Similarly, if limited
areas are present over the breasts or anterior abdomen in
Fig. 34.5A: A 22-year-old female with hypopigmented post burn
scars over both breasts
Fig. 34.5B: Early result after excision and over-grafting with thin
split skin grafts
females, treatment has to be offered (Figs 34.5A to 34.6B).
The surgical treatment should begin after the maturation of
scar and usually takes the form of excision/dermabrasion
and over grafting with thin split skin grafts. Post-operative
hyperpigmentation should be prevented by religious
avoidance of exposure to sunlight. Although color may not
be exactly like the surrounding skin but the results are always
very satisfying when compared to initial problem. Very small
areas may be treated by tattooing of appropriate pigment in
the vitiligo area.
Fig. 34.6A: A 25-year-old female with hypopigmented post burn scars
over abdomen, an area usually exposed while in traditional Indian
dress "Saree"
Fig. 34.6B: Result at 6 weeks after excision and over-grafting with
thin split skin grafts

Post Burn Sequelae and their Management
473
Patients may also present late with mature scars along
with one or more of other post burn sequelae. They need
detailed assessment of the functional and esthetic needs
and planning of priorities and order of surgical interventions.
POST BURN CONTRACTURES13,14
A patient who receives the best of modern burn treatment
is expected to heal without any contracture. However,
contractures, like bed sores, do form even in the best of
facilities. This is because contraction is a strong natural
force and difficult to counter. Moreover, life-threatening
complications in acute stage may compromise on problems
which can be tackled later. Unfortunately, the incidence of
post burn contractures is extremely high in our country.
Quite often, they are not only multiple in a given patient but
also very severe and diffuse. This is because the majority
of the millions of burn victims in our country have no access
to a trained burn specialist. The number of trained burn and
plastic surgeons is too small in our country. It is around
one thousand for more than a hundred crore (one billion)
population. The burn patients are treated not only by a general
surgeon but also by general practitioners of all systems of
medicine, quacks (Fig. 34.7) and even patients and their
relatives themselves. In this scenario, the aim and end point
of a burn injury management is, unfortunately again a healed
wound only. However, this healing (actually contraction)
does not stop here and continues till multiple severe
contractures result. A contracture is, thus, the end result of
the process of contraction. When the contracture is opposite
a joint, it leads to a functional deficit in its full range of
motion. Thus, while contractures of the lower extremity
interfere in upright ambulation and wearing of ordinary
shoes, those of the upper extremity interfere in all the day-
to-day activities of the individual. The non-joint contractures
like ectropion of eyelids endangers vision and that of lips in
normal eating and lip seal apart from poor esthetic
appearance. It is at this stage that most of these patients
move on to the metropolitan cities in search of a plastic
surgeon who can now treat them. Patients of post burn
contractures, defects and disfigurements constitute almost
half of the workload of many general plastic surgeons,
especially the ones in government institutions.
Mechanism of Burn Wound Healing and
Development of Scar and Scar Contracture
An understanding of the burn wound healing15,16 is
fundamental not only to the management of the acute burn
wound, but also for the prevention, minimization and
treatment of post burn scars and scar contractures. The
healing of a burn wound is accomplished in two ways,
namely, complete regeneration (restitution) and substitution.
Restitution is possible only if the skin is burnt as deep as the
stratum papillare and all the specialized cells of the organ
are preserved. The epithelial cells, in these cases, are derived
from the epithelial appendages such as pilosebaceous units
and sweat glands in the central portion and wound edges at
the periphery. These appendages extend into the deeper
dermis and may even penetrate into the subcutaneous fat
(as in beard area in males) and survive in partial thickness
injuries. The sequence of cellular events that comprise
epithelialization include cellular detachment, migration,
proliferation and differentiation. If the skin is affected deeper
in the zone of stratum reticulare, the defect is covered by
substitutive unspecialized connective tissue. The final result
is demonstrated by a lesser or more extensive formation of
the cicatrix. With full thickness loss of skin, wound
contraction and epithelialization from the margins occurs
leading to contractures.
Contraction is an active biological process by which an
area of skin loss in an open wound is decreased due to
concentric reduction in the size of the wound. It is a vital
part of spontaneous healing of open wounds and perhaps
nature's attempt for closure of the wounds. The reduction
in size of wound causes lesser degree of connective tissue
deposition and the amount of epithelialization needed is
decreased. Wound contraction is a satisfactory mechanism
when the tissue loss is small, in a non-critical area and
Fig. 34.7: Patient being treated by quacks with application of indigenous
mixture of 'Ratanjyot' (an edible coloring agent) and camphor in coconut
oil.

474
Principles and Practice of Burn Care
surrounded by loose skin. A small full thickness burn over
medial thigh, calf area or abdomen may heal satisfactorily
by contraction aided by epithelialization from the margins.
In a fingertip injury or small scalp loss, contraction may be
desirable so as to have specialized sensitive and hairy skin
respectively to cover the wound.
Scar contracture, on the other hand, is the end result of
the process of contraction occurring in a healed scar. There
is excessive scar formation across the joints resulting in a
functional and esthetic deficit.
Associated Local Conditions in Patients with
Contractures
A post burn contracture may be associated with additional
problems on the skin and/or in the deeper tissues.
On the Skin
There may be:
i. A hypertrophic scar/keloid or an atrophic scar.
ii. An unstable scar over flexor aspects of joints/chronic
non-healing ulcer(s) over non-joint areas which may
or may not heal over prolonged periods of time/chronic
postburn massive raw areas which are not expected
to heal of their own ever (Figs 34.41A to 34.42B)
iii. Depigmented/hyperpigmented scar
iv. A Marjolin's ulcer.
Presence of one or more of above along with a
contracture may alter the physical therapy and/or surgical
treatment of a contracture. For example, an unstable scar
or chronic non-healing ulcer(s) needs their surgical excision,
release of contracture and provision of skin cover. Physical
therapy in the form of exercises, massage and pressure
garments prior to surgery is not possible in these cases.
Bigger raw areas need wound closure with skin grafting
before contracture can be subjected to physical therapy
(Figs 34.41A to 34.42B) Wide excision of Marjolin's ulcer
has to be combined with release of contracting bands (Figs
34.47A to E). A post burn contracture associated with a
hypertrophic scar or an atrophic scar or a depigmented
scar needs excision-release of all to achieve best results
not only functionally, but also esthetically.
In the Deeper Tissues
The deeper tissues may be affected either due to their
involvement in the initial burn injury (e.g. electrical burns)
or secondary to the presence of a skin contracture over a
prolonged period of many years which leads to shortening
of musculo-tendinous units and neurovascular structures.
Contractures of fingers following electrical burns are
invariably associated with loss of underlying flexor tendons
and need flap cover, even if a split skin graftable bed is
present, because of the need for tendon grafting later. In
addition, there is greater risk of digital circulation becoming
compromised on straightening the finger as compared to
patients with thermal burns. The joints may be subluxated or
dislocated with joint capsule and ligaments becoming tight in
the direction of the contracture especially when adult patients
present for treatment of burns sustained in early childhood.
The bones may be deformed specially in growing children,
e.g. mandible may be deformed due to chronic pull in cases
of severe post burn contractures of the neck (mentosternal
contractures) (Figs 34.43A and B).
The shortening of deeper structures has great clinical
significance. It may not be possible to release the contracture
fully at the time of operation because the neurovascular
structures, tendons and muscles may stand out as bowstrings
limiting any further release. Moreover, the vessels may also
go into spasm with compromise of distal limb or digit
circulation due to excessive stretch. There may be prolonged
neurapraxia due to nerve stretch. The muscles/tendons may
resist any lengthening by forceful pull even under general
anesthesia. Such contractures need release and dressing of
the wound followed by sustained traction using various
methods for complete correction. This can generally be
achieved within two weeks. Skin cover is provided only
after complete or maximum possible correction is achieved
(Figs 34.12A to D). In occasional circumstances, when the
patient presents with severe post burn contractures of elbow,
wrist, knee etc. decade(s) after sustaining the burns in
childhood, it may not be possible to achieve complete release
and correction at all (Figs 34.8A to D). When bones and
joints are also affected, orthopedic consultation may be
needed. When mandible is deformed along with loss of
normal dental occlusion in severe and untreated post burn
contractures of neck in children, orthodontic/orthognathic
measures are needed after the contracture is fully treated.
Timing of Surgery in Post Burn Contractures
As a rule, surgical intervention for post burn contractures
should not be undertaken during the active phase of healing
and scarring, i.e. as long as the scar is immature and highly
vascular. This usually takes one year or so. One must allow
the scar to become mature, soft and supple and 'avascular'

Post Burn Sequelae and their Management
475
before undertaking surgery for contractures. This is because
a highly vascular scar bleeds more during operation with
difficulties in achieving perfect hemostasis resulting in poorer
graft 'take' leading to healing by further contraction.
Secondly, operation on an active, highly vascular scar with
wound bed still in active phase of contraction, adds insult
to already traumatized tissues with vigorous local response
in the form of further contraction. All these lead to a less
than perfect result. Moreover, an immature scar is amenable
to physical therapy measures resulting in significant
improvement even non-surgically. With the passage of time,
some mild contractures may improve with a better final
result than if they had been surgically managed. Hence, one
must get benefit from this therapy before any operative
intervention. Time is a great healer, not only of the emotional
trauma but also of the wounds and scars of the skin! The
patients also develop more realistic expectations during this
waiting period, due to their interaction with other patients
who are in their last stage of reconstructions. Lastly, it must
be remembered that physical therapy is the mainstay of
achieving best results even after surgical intervention. A
patient who is non-compliant prior to operation is likely to
get a poor or an average result postoperatively with all the
blame being put on the surgeon especially in this era of
Consumer Protection Act.
A burn surgeon must never be guided or influenced by
the patient, his or her relatives, higher authorities or even
politicians to do 'something operative' at the earliest.
However, there are many exceptions to this general 'rule' of
scar maturation. In these cases the results may be
compromised and they may need another surgery at a later
date.
i. Ectropion of the eyelids, especially the upper eyelid
with constant danger of keratoconjunctivitis, corneal
ulceration, scarring or perforation with loss of vision.
ii. Incapacitating contracture of the neck with inability
to look forwards.
iii. Severe microstomia interfering with adequate nutrition
and maintenance of orodental hygiene.
iv. Crippling contractures of hand,17,18 especially dorsal
contracture with metacarpophalangeal joints going in
hyperextension leading to permanent damage to
extensor mechanism with various deformities.
v. Contractures of both the knees, which force the
patient to be on 'all the fours' and endangers the very
dignity of being an upright human being.
vi. Post burn contractures with associated adjoining
chronic raw areas needing skin cover.
Figs 34.8A and B: Severe contracture of elbow and wrist
secondary to burns sustained at the age of 1 year
Figs 34.8C and D: Suboptimal result after release and skin grafting is
attributed to bony deformity and contracted ligaments, joint capsule
and musculotendinous units
A
B
C
D

476
Principles and Practice of Burn Care
vii. Contractures with infected hypertrophic scars and
abscesses, which need excision/drainage for their
recovery.
viii. Any severe, incapacitating contracture unlikely to
improve at all with physical therapy measures.
Priority of Release in Cases of Multiple
Contractures
A large percentage of patients coming to a burn surgeon
have multiple contractures in different parts of the body. It
is obvious that all of them cannot be released in one stage.
In addition, there may be other reconstructive needs, e.g.
reconstruction of scalp, nose, pinna, and face, etc. Quite
often, there may be limitations due to paucity of healthy
donor sites for skin grafts and flaps. Release of contractures
and reconstruction in such patients may take many years.
Therefore, a definitive strategy is essential in planning to
reduce the number of anesthetic and surgical procedures
and yet provide the best functional and cosmetic result safely.
With each stage the patient must be able to appreciate the
result and improvement. This adds to the surgeon's strength
and patient's compliance and morale. It is ideal that this
plan of action is put in black and white before the treatment
is started and kept in patient's records along with a copy to
patient.
An ectropion of the eyelids, especially the upper eyelid,
with its attendant risks needs to be dealt with first to prevent
irreparable damage. One must remember that loss of vision
due to burns per se is rare expect for chemical burns (Figs
34.9A and B, 34.29A to E) It may even be managed under
local anesthesia in case of an adult. Similarly, a severe
contracture of the neck or microstomia leading to difficulties
in intubation should be corrected before planning any other
contracture release or reconstructive procedure requiring
general anesthesia. This takes care of repeated intubation
difficulty with its all the attendant risks. Additionally, the
complete release of a neck contracture removes the extrinsic
pull on facial structures (lips, chin and even lower eyelids)
and contractures of the axilla and the breast. For full release,
the neck contractures need division of platysma and fascia
until the strap muscles are seen.
Contractures of the hand need to be addressed after the
neck is treated. They are not only crippling and interfere in
the day-to-day life, studies and earning, but may also cause
permanent damage to the delicate balance of tendon
movement. This is especially true of contractures on the
dorsum of hand. A dorsal contracture of the hand with
Fig. 34.9A: Young adult with very severe ectropion of right upper and
lower eyelids, loss of vision, with facial disfigurement
Fig. 34.9B: Simultaneous release and split skin graft of both eyelids
done without waiting for scar maturation. Result after 4 months. Please
note the maturation of other scars with massage and passage of time
metacarpophalangeal joints in extension not only stops the
function, but also wrecks the machinery (extensor apparatus)
(Figs 34.10A to D). Here, it must be noted that both hands
should rarely be treated together (except in small children)
to allow the patient his/her daily needs of feeding and toilet
care (Figs 34.11A to D). Also, the hand with greater

Post Burn Sequelae and their Management
477
Fig. 34.10A: Post burn contracture and severe hypertrophic scar
on dorsum of both hands and wrist
Fig. 34.10B: Intraoperative: Complete excision of hypertrophic scar
and release of contracture (Right hand)
Figs 34.10C and D: Result at 1 year with full range of movement at
MP joint with pleasing esthetics
C
D
Fig. 34.11A: A Post burn contracture on dorsum of both hands and
wrist in an 8-year-old-child
Figs 34.11B to D: Release and split skin grafting with complete
restoration of hand and wrist function. Result after 5 years
B
C
D

478
Principles and Practice of Burn Care
likelihood of becoming more functional should be treated
first rather than the right hand (in a right handed person),
which may be almost irreparably damaged. Conversely, the
hand which may be retrievable today and considerable
damage is expected with any further delay, should be
operated first, even if severely affected. When axilla, elbow
and hand are all affected on one side it may not be possible
to operate on the hand till the axilla and elbow are released.
Contractures of the popliteal fossa also need early
intervention as they are also highly incapacitating (Figs
34.12A to E).
The order of management of other contractures depends
upon the surgeon's evaluation of the remaining reconstructive
needs, feasibility of combining multiple procedures in the
same surgical sitting, availability of donor sites, scope of
improvement and the patient's desires.
Prevention of Wound/Scar Contraction and
Scar Contractures
In a healed burn patient, the healing may have been achieved
by one or more of the following:
i. Spontaneous healing with epithelialization and
contraction.
ii. Split-skin grafting over granulating raw areas after
spontaneous eschar separation
iii. Early excision and split-skin grafting.
In all these patients, various physical therapy measures
are immediately instituted for the healed burnt areas and
split-skin donor sites to minimize scars and scar
contractures. It is to be noted that physical therapy in a
burn patient actually begins on the day of admission. This
may take the form of limb elevation, crepe bandages to
reduce edema, active and passive joint movement, splintage
and positioning of the body parts in anti-deformity posture,
functional position, etc.
Due to prolonged contractile nature of the burn wound,
a patient who heals initially with full range of motion may
develop severe deformities as the healed skin/scars mature
and hypertrophic scarring occurs. Dermatological problems,
e.g. blister formation, its breakdown, excessive dryness
and cracking can occur or a gradual build up of hypertrophic
scar tissue can lead to a rapid decrease in motion and
functional ability. Thus, the physical therapy measures have
to be continued till the scars have matured and no further
change is expected. During continuation of this therapy,
various surgical interventions may also be needed and
undertaken. It is only when all the scars have matured, the
Fig. 34.12A: Severe contracture of both knees and right ankle in a
3-year-old girl precluding ambulation
Fig. 34.12B: Complete release was not possible in one go; serial
splintage done over 2 weeks. Please note the straight limbs and healthy
granulations
Figs 34.12C and D: Grafted and all wounds healed
C
D

Post Burn Sequelae and their Management
479
correctable deformities looked after, reconstructive surgeries
performed and no further reasonable improvement is
expected that the treatment of a burn patient is called off
(except probably continued psychological support and aid
for return to society).
The control of wound/scar contraction and scar
contracture is done by the following techniques:
1. Skin Grafting19-22
The single most important and effective method of
controlling the wound contraction is to close the wound at
the earliest. This is done using split-skin grafts in deep dermal
and full thickness burns. Contraction can be inhibited by
applying grafts to fresh wounds (as in early excision) or
over healthy granulating areas (after eschar separation). Full
thickness skin grafts inhibit contraction almost completely.
Unfortunately, in a clinical setting, the raw areas of burns
have to be covered with split-skin grafts so that the donor
sites can heal on their own and may even be re-harvested.
The split skin grafts may have to be expanded with meshing.
Although this leads to complete healing of the wound, the
latter is largely covered with epithelium in the interstices of
the meshed graft.
It is widely believed that thicker the graft, greater will
be the inhibition of contraction. This holds good only if the
grafts are harvested from a given site. The fact is that when
split-skin grafts are harvested from different sites, it is the
total percentage of dermal thickness grafted which
determines how much contraction will be inhibited. Delayed
application of skin graft does not inhibit contraction as
effectively as immediate grafting.
2. Pressure Garments23-27
Deep dermal burns and donor sites of intermediate and thick
split-skin grafts frequently develop hypertrophic scars. They
must be prevented or treated using pressure garments (Figs
34.13A to F). These compression garments quickly reduce
the mass of immature hypertrophic scars. The effectiveness
of these garments decreases after the development of mature
Fig. 34.I2E: An untreated popliteal and ankle contracture due to burns
sustained in infancy leading to limb shortening with subluxated knee
joint
Fig. 34.13A: Post burn hypertrophic scar in healed
deep dermal burns
Fig. 34.13B: Pressure garment

480
Principles and Practice of Burn Care
hypertrophic scars. Before prescribing commercial pressure
garments, the newly healed skin must be preconditioned to
accept the stress and pressure exerted by the garments. For
this, initially gentle pressure is applied with crepe bandages.
As the skin 'toughens', the commercial pressure garments
may be prescribed. In the hot and humid conditions of our
country, it is difficult to wear them continuously for a period
of 24 hours a day. Hence, compliance is a great problem not
only in children but also in adults. They have to be worn for
a period of at least 9-12 months to be of benefit.
Although application of pressure to influence the
abnormal scars has been used for the last two centuries, it
is only in the last fifty years that it has been popularized and
its mechanisms of action studied. A reduction in fibroblast
content, total chondroitin-4-sulphate, cohesiveness of
collagen fibers and rapid disappearance of collagen nodules
(normally found in hypertrophic scars) and reorientation of
the collagen bundles have been noted. A reduction in
intralesional mast cells and their histamine production and
release has also been demonstrated. Pressure therapy
diminishes the number of myofibroblasts, erythema,
thickness and firmness of hypertrophic scar and accelerates
its maturation.
The exact mechanism(s) whereby the pressure therapy
works is still not known. However, the various explanations
put forward for these changes are (a) hypoxia of the scar
tissue by occlusion of the microvasculature, (b) increased
collagenase mediated collagen breakdown due to pressure
induced decrease in capillary blood flow, (c) reduction in
tissue edema with less ground substance due to compression
(d) neutralization of local venous hypertension by preventing
leakage of plasma proteins and improving tissue oxygenation
(e) elevation in skin temperature by 1-3degrees by blockage
of heat loss from the cutaneous surface, etc. The ideal
pressure required is also not clear but it must be more than
24 mm Hg for capillary pressure to be countered. While
significantly lower pressures may not work, a pressure above
40 mm Hg may not be tolerated with appearance of
paresthesias and maceration.
3. Splintage and Exercises28,29
The scar collagen and elastin are relatively uncross-linked
and malleable during their initial deposition. Gentle, passive
and sustained stretching using various dynamic and static
splints exploits this malleability and is an effective technique
for the lengthening of bands of scar tissue and increasing
the range of motion (Figs 34.14A to E). Combination of
paraffin wax bath application with positions of sustained
stretch using serial splintage is highly effective. When several
Figs 34.13E and F: Hypertrophic split skin graft donor site being
treated with pressure garment. Note the markings of the garment cloth
on the skin on turning down the pressure garment
Fig. 34.13D: Pressure garment
Fig. 34.13C: Post burn hypertrophic scar in healed burns
E
F

Post Burn Sequelae and their Management
481
Figs 34.14A and B: (A) A 27-year-old female with multiple contractures
and immature, hyperemic scars. (B) Result 18 months later, the
contractures have been treated and the scars matured with greatly
diminished vascularity. Please note the improved breast contours due
to diminished upward pull and softening of mature scars. No surgical
intervention can be worthwhile for extensive hypopigmented areas
Figs 34.14C and D: (C) Postoperative lateral view of neck. (D) Chin-
neck pressure garment and cervical collar is worn for 6-9 months to
provide splintage for favorable maturation of graft
Fig. 34.14E: Various splints used for post burn patients
A
C
D
joints are involved, the contractile nature of the scar must
be remembered and body positions devised that provide
stretch along the length and breadth of the area involved.
Thus, in patients with scars involving both of the upper
limbs, axillae, anterior chest and neck, a pillow is placed
under the shoulder and upper limbs are kept in maximum
abduction. The paraffin is applied to the patient in this
position and left in place for 20-30 minutes of sustained
stretch.
4. Massage
The healed burn wounds and donor sites of split-skin grafts
are massaged with lubricants like coconut oil or one of the
various proprietary creams and oils. The massage causes
increased flow in the veins and the lymphatics thereby
increasing the absorption of metabolic wastes. There is an
increase in capillary circulation and mobility of subcutaneous
soft tissues. The lubricants are applied lightly and rubbed in
gently after a thorough bath. Heavy lubrication is avoided
as their build-up on the skin causes pimples and furuncles.
Massage should be done with care to avoid friction to
superficial layers of skin (neoepidermis/scar epithelium) that
can cause blisters. This is due to the absence of desmosomes
between neoepithelium and underlying tissues. There are
psychological benefits also as it helps to relax the patient
and creates a feeling of well-being. Last but not the least, it
buys time for the surgeon before the time is appropriate for
surgical intervention.
5. Silicones30
The silicones have been used in various forms for prevention
and treatment of hypertrophic scars (Figs 34.15A and B).
These are synthetic polymers based on dimethylsiloxane
monomer with polydimethylsiloxane (PDMS) being the
commonest in use. Silicone gels having lightly cross-linked
chains of PDMS are available as sheets and have to be worn
for 24 hours a day with particular care being taken of local
hygiene to avoid the development of contact dermatitis and
folliculitis. The exact mechanism of action of silicone gel
sheets is not known. It may exert its effects by increasing
the temperature of the scar, thereby enhancing the activity
of collagenase, which is known to increase several folds
over 1 to 2°F increase of body temperature. Other effects
of silicone gel, such as increased pressure, lowered oxygen
tension and occlusion may be less important. Hydration of
the stratum corneum and direct release of low molecular
weight silicone fluid into the scar are other possible modes
of action. However, silicone does not appear to enter scar
B

482
Principles and Practice of Burn Care
tissues. The biggest drawback of silicone gel sheets is the
practical difficulty in keeping the sheet in contact with the
scar all the day and night and their application on exposed
areas of the body like face is unsightly.
any one time is limited for a very small lesion only. Not
more than 80-120 mg should be injected in adults in one
sitting in a concentration of 8-10 mg/ml. The available vial
of 40 mg/ml. can be diluted with 3ml of 1% lignocaine to
decrease the pain of injection. Addition of hyaluronidase
may improve the spread of drug into scar tissues. The main
complication of atrophy is due to over-dosage and spillage
into normal skin or subcutaneous tissues. Telangiectasia
and hypopigmentation can also occur. Hirsutism can be an
annoying problem in young females.
7. Management of Pruritis31,32
Itching is an extremely common complaint of patients with
healing and healed burn wounds and donor sites especially
at night. Patient's scratching the area to get relief causes
breakdown of recently formed neoepithelium with
consequent ulceration, the healing of which again causes
itching, thus forming a vicious cycle. The ulceration(s) may
become infected. This prevents application of many of the
above-mentioned measures for minimizing scar contraction
and optimizing its maturation. Even after many years, the
patients may still complain of this problem. Pruritis affects
the daily life and emotional well-being reminding the traumatic
event again and again. In some patients this is perceived as
pain although the mechanism of both is same. The treatment
of post burn pruritis is difficult and frustrating to the patient
and the burn surgeon alike. Oral antihistaminic drugs like
pheniramine, promethazine, cetrizine etc. are commonly
prescribed, especially at bedtime. Steroid containing creams,
if at all used for local massaging, must be avoided over
areas exposed to sunlight for fear of hyperpigmentation. As
the dry skin is especially prone to itching and the healed
areas may be deficient in production of sweat and sebum,
keeping the skin well lubricated with moisturizers and oils
is very essential. Newer therapies in the form of Gabapentin,
H1 and H2 blocker combination therapy, topical application
of histamine receptor blockers and transcutaneous electrical
nerve stimulation have been introduced with variable results.
Surgical Intervention
The surgical management of any post burn contracture
involves the following steps:
Release of Contracture
Complete release of contracture should be done avoiding
damage to any important underlying structure, e.g. arteries,
Figs 34.15A and B: (A) Post burn hypertrophic scars over
anterior trunk (B) Application of silicon gel sheet
Silicone in the form of gels, creams and ointments
containing short, straight and unbound chains of PDMS
are being increasingly promoted as they are simple to use,
do not need any tapes to hold them, are not unsightly and
maintaining hygiene is easy. A very thin film is applied over
the hypertrophic scar and allowed to dry over 4-5 minutes.
On drying, it forms a thin, impervious and almost invisible
film. It is applied twice daily. Xeragel®, Vaniza gel®, Kelo-
Cote® etc. have recently become available in the Indian market.
6. Intralesional Steroids
Intralesional injections of triamcinolone, every 4-6 weeks,
have been in use for over 40 years and found to be effective
for control of hypertrophic scars and keloids. Triamcinolone
is a powerful steroid that exerts strong anti-inflammatory
activity. It can be used in early stages of hypertrophic scar
formation when the scar is comparatively soft and easy to
inject. It can also be used in mature scars but because of
their hardness it may be very difficult to inject especially in
first couple of sittings. On being injected into a hypertrophic
scar, it activates the endogenous collagenase to degrade the
mature collagen to more soluble forms. After a number of
injections the hypertrophic scars become flattened, softened
and non-pruritic. However, the dose and amount injected at
A
B

Post Burn Sequelae and their Management
483
nerves, tendons, etc. Although contraction occurs in all
directions, the incision should begin across the point of
maximum tension, i.e. where the contracture is most tight.
This point is usually opposite the joint line. The incision is
deepened all the way to the unscarred, healthy tissues. After
the complete release of contracture, multiple darts are made
at appropriate points along the periphery of the defect created
to take into account the contracture along other directions.
Fish- tailing of the incision line at either end is inadequate
and inferior to the multiple darts especially when the former
are marked on the skin at the beginning of operation. Darts
are 'cut as you go' while the fish-tails are predetermined.
No attempt should ever be made at undermining the
surrounding healthy/scarred skin and advancing it to
decrease the defect. Incision line can be infiltrated with
1:200,000 adrenaline solution either alone or preferably
mixed with lignocaine one percent to have a relatively
bloodless field (Maximum dose of adrenaline is 5
micrograms/kg body weight and that of lignocaine is 7 mg/
kg body weight). The limb contractures, especially distal to
arm/thigh, should be released under tourniquet control,
whereever possible. Bipolar cautery should be used to
achieve accurate hemostasis during release incision. When
a contracture is released under tourniquet, hemostasis is
done once again after deflation of tourniquet. The raw area
should now be covered with1:200,000 adrenaline solution
soaks and skin graft harvested.
Incision versus Excision
In general, a contracture should be released by incision rather
than by excision. This is especially true for patients who
have received adequate preoperative physical therapy and
their scars have become soft and pliable. Incision alone
decreases the requirement for skin cover. When the scars
are extensive, it is futile to excise a small amount if whole
of scar cannot be excised for fear of creating an extensive
raw area. Excision may, however, be required in certain
circumstances e.g., (a) small adjoining depigmented or
hypertrophic areas, excision of which will add to the final
aesthetic result (b) atrophic/unstable scars/chronic non-
healing ulcer(s) should be excised along with release of
contracture to obtain healthy bed for split-skin graft 'take'
(c) scars may also be excised so as to apply the graft/flap
in accordance with principles of esthetic units. Partial
excision of hypertrophic scars may sometimes be done,
e.g., in a case of post burn contracture of neck, the scars
may extend from chin, neck on to the chest and even
abdomen. Here, only neck scars are excised. Before excision-
release is planned, the size of the defect created must be
estimated beforehand and availability of required donor site
for skin graft/flap assessed.
Immediate versus Gradual Release
In general, a contracture should be released completely on
the table in one go. However, in severe long-standing
contractures, there is considerable shortening of musculo-
tendinous units and neurovascular structures. Hence, it may
not be possible to achieve complete release. Their exposure
may limit any further release and vessels may go into spasm
if forceful extension is attempted, especially in contractures
of limbs. Similarly, when the joints are subluxated or
dislocated, immediate complete release may not be possible.
In all these cases, contracture is released as much possible
and the wound is dressed. Full correction is achieved
gradually over a period of up to a couple of weeks using
serial splintage with Crammer wires, skin/skeletal traction
or the modern distractor systems. Once full/maximum
correction is achieved, skin cover is provided (Figs 34.12A
to D). If split skin graft is applied immediately, the smaller
size of the graft applied limits the full extension and/or else
a halo of raw area appears around the graft on attempted
serial splintage. The graft 'take' on uneven raw area may
also be less than satisfactory. In addition, any future attempt
at release may not be possible because these structures will
be lying just under the graft.
Provision of Skin Cover
After the complete release of a post burn contracture, the
recreated defect is covered using skin grafts or a skin flap.
Commonly, the raw areas resulting after release of post
burn contractures are covered with split skin grafts. Flap
covers are used in special situations only.
Skin Graft: When using split skin grafts, sheet grafts are
to be preferred and no attempts should be made to expand
the graft by meshing. As far as possible, try to feed in graft
more than the size of the defect to take care of the post-
operative, inevitable secondary contraction. The junction
line of the sheets of the grafts should preferably lie parallel
to the axis of joint motion. Ordinarily, the skin grafts are
applied immediately after complete release. Sometimes,
delayed application after 5 days, once the granulations form,
is done. The delayed approach is required when release of
contracture results in exposure of fat which is a poor bed
for graft 'take'. When the raw areas are oozing a lot, or
when the contracture is associated with infected areas,

484
Principles and Practice of Burn Care
delayed application gives a better result. When skin grafts
have been used, rigid immobilization is done by one or more
of the various techniques, viz. 'tie-over' dressings, plaster
of Paris splints, crepe bandages, elastoplasts, etc. depending
upon the site.
Split Skin Graft versus Full Thickness Skin Graft
In general, all contractures should be treated with split-skin
grafts of intermediate or thick variety. This allows the donor
site to heal spontaneously. Moreover, extensively burnt
patients with multiple contractures have paucity of donor
sites. Full thickness grafts, although better than the split-
skin grafts in most of the properties, have poorer chances
of 'take' and their donor sites in turn need split-skin grafts.
Their use is limited to very small defects resulting after
release of contracture in esthetically important areas, e.g.
ectropion of the upper lip, lower eyelid, etc.
Skin Flaps: There are a few situations where a skin flap is
a must. If the contracture release is likely to open up the
joint, especially of the hands and feet, or tendon/nerve
surgery is planned at a later date, e.g., old healed electrical
burns, a flap cover must be provided after release of
contracture. If release of contracture results in a moderate
defect in a cosmetic area, which if covered with a flap will
give a better aesthetic appearance, a flap cover may be
provided. For example, an ectropion of the upper lip in an
adult male can be released and covered with a flap from the
scalp or upper neck to restore moustaches. In a female, the
same ectropion requires a graft cover. A groin contracture
may be treated using a tensor fascia lata flap with graft on
the flap donor site (Figs 34.16A and B). This decreases the
need for postoperative splintage to prevent secondary graft
contraction.
If a local flap in the form of Z plasty, V-Y plasty, V-M
plasty, etc. (for linear/webbed contractures) will be
sufficient in itself to treat the contracture, there is no reason
why they should not be used alone (Figs 34.17A and B).
However, these flaps are always in danger of necrosis when
raised in scar tissues. Moreover, they are possible only in
very mild cases. They are also useful when massive diffuse
contractures are treated with split skin graft and later on,
after graft maturation, contracting bands form at the graft-
surrounding skin junction. The flaps used for provision of
cover may be local, regional or distant. They may be free
or pedicled.
The biggest advantage of using a flap for treating a post
burn contracture is that post-operative prolonged splintage
Fig. 34.16A: Young adult female with contracture of right groin
region with umbilicus pulled downwards and laterally
Fig. 34.16B: Release and cover with transposition of tensor fascia
lata flap whose donor site was split skin grafted. Postoperatively the
patient does not require any splintage

Post Burn Sequelae and their Management
485
from the limbs can be harvested using Watson's skin grafting
knife, electrical dermatome is ideal for abdomen and back.
It should be noted that in every patient who presents with
multiple post burn problems which need to be addressed
surgically, one must look for the donor sites available. In a
case with multiple, massive contractures, the donor sites
should be checked and a plan charted out for 'which donor
site for which contracture'. This is important as large sheets
are usually required for neck, axilla and facial resurfacing,
etc. while comparatively smaller pieces of grafts are
adequate for contractures of fingers, eyelids, etc.
Postoperative Care
Maintenance of released/corrected position is mandatory
until the graft has become stable (usually 3 weeks) or till
the flap margins have healed.
Postoperative use of static or dynamic splints,
interspersed with a routine of daily physical therapeutic
exercises is required to keep the joints in full range of motion
(especially if static splintage is used). This therapy is
continued till the grafts have matured (usually 9 to 12
months) and complete range of motion is achieved.
Maturation of the graft is aided using massage with
lubricants, use of pressure garments and silicone gel sheets,
etc. for a period of 1 year or more, till the graft loses its
tendency to contract and can be pinched and mooved over
the recipient area. Lubrication of the split skin grafts over
large areas should be advised indefinitely because of absence
of sebaceous and sweat glands in the grafted skin.
The detailed account of surgical technique for the
correction of each and every individual post burn
contracture-deformity and various local, regional and distant
flaps described in literature for providing cover is beyond
the scope of this chapter. The commonly seen contractures
are ectropion of the upper and lower eyelids and lips, neck,
axilla, elbow, hand, breast, groin, knees, ankle and toes.
From time-to-time, many workers have tried to classify the
contractures of different sites. The present author does not
find them useful in treating his patients. Classifying them as
mild, moderate and severe is of no consequence as a mild
contracture of lower eyelid causes epiphora, upper eyelid
may endanger cornea and popliteal fossa leads to an unstable
scar-ulcer and even development of malignancy. On the
other hand, a moderate flexion contracture of fingers or
axilla may allow normal daily functions to be carried out.
Moreover, it is difficult to quantify what constitutes mild,
moderate or severe for different areas and in different
Fig. 34.17A: Contracture of both axillae
Fig. 34.17B: Right axilla treated by release—excision of scar
contracture and multiple Z plasty
is not required. However, in a practical clinical scenario
with patients of extensive burns with multiple sequelae, the
appropriate flap may not be available. Moreover, the healthy
unscarred skin of the flap may stand out prominently in the
midst of surrounding scarred or skin grafted areas. Their
donor sites also need split skin grafts for closure. The grafts
blend far better in such surroundings. In patients with smaller
burns and limited needs for reconstructive surgery, an
appropriate local, regional or distant flap may be used to
provide cover after release of contracture.
Donor Sites. The split-skin grafts are usually harvested from
thighs. However, in a severely burnt patient, with extensive
scarring, the grafts may have to be harvested from legs,
upper limbs and abdomen, back or even scalp. While grafts