CVR Physiotherapy › Chapter 6 › 6(g) Burns
Burns: acute care, positioning, splinting and inhalation injury
Burns came up in 19 of the 20 papers from 2016 to 2026 (all except Summer 2023). The long answers give a burn site and percentage, then ask for ICF, positioning and splinting, and a phase-wise plan. Recent cases add a child, a full-thickness facial burn with breathing difficulty and a pregnant woman.
- Syllabus
- Ch 6(g) Burns: head, face, neck and thorax, inhalation burns; acute care management
- Priority
- Tier 1. In 19 of 20 papers (2016–2026). 12 long-answer cases, second only to IHD and CABG.
- Asked as
- LAQ S16W16W17W20S21S22W22W19W21S24W24S26 7m S17W17S18W18S20W22S24S25W25 3m W16W18S19 ×2S20S24S25
- Usual split
- 5 + 5 + 5 (ICF, short-term, long-term), or 6 + 6 + 3 and 5 + 7 + 3 with an add-on such as rule of nines or wound healing
- Checked against
- ISBI Practice Guidelines for Burn Care (2016, 2018); American Burn Association fluid resuscitation guidance (2023, summarised 2025); Cochrane review of pressure garments (2024); burn-unit mobilisation protocols. Full list under Sources.
- Content checked
- 19 October 2026. Next review due October 2027.
- My revision
-
1Definition
A burn is an injury to the skin and deeper tissues caused by heat, electricity, chemicals, radiation or friction.
An inhalation injury is damage to the airway and lungs from breathing in hot gases, smoke or toxic products of burning.
The burn wound is described by three things: its cause, its depth, and its extent as a percentage of total body surface area (TBSA).
2Classification and grading
By cause
- Thermal: flame (stove, kerosene, firecrackers), scald (hot liquids, commonest in children), contact (hot objects).
- Electrical: low or high voltage, and lightning. Small skin wounds can hide deep muscle damage.
- Chemical: acids and alkalis. Alkalis penetrate deeper.
- Radiation and friction.
- Inhalation injury, which often comes with face and neck burns.
By depth (asked as 3 marks in W16 and S20; 7 marks in W17)
| Depth | Look and feel | Healing |
|---|---|---|
| Superficial (first degree): epidermis only | Red, dry, painful, no blisters. Blanches on pressure. Example: sunburn. | About 3–7 days, no scar |
| Superficial partial thickness (second degree): epidermis + upper dermis | Blisters, pink and moist, very painful, blanches and refills quickly | Within about 2–3 weeks; little scarring |
| Deep partial thickness (second degree): into deep dermis | Blotchy red and white, drier, less painful (pressure felt more than pain), slow or no blanching | More than 3 weeks; high risk of hypertrophic scar; often grafted |
| Full thickness (third degree): whole dermis | White, brown or black, leathery (eschar), painless because nerve endings are destroyed, no blanching | Cannot heal except from the edges; needs skin grafting |
| Fourth degree | Through fat into muscle, tendon or bone | Needs flaps, sometimes amputation |
Burn depth through the skin
By extent: Wallace's rule of nines (3 marks in W18; 3 marks inside S21)
Rule of nines, adult (front and back)
Text version (write this as the answer)
- Head and neck: 9% (front 4.5, back 4.5).
- Each upper limb: 9% (front 4.5, back 4.5), so both arms 18%.
- Front of trunk (chest and abdomen): 18%. Back of trunk: 18%.
- Each lower limb: 18% (front 9, back 9), so both legs 36%.
- Perineum and genitals: 1%.
- Palm method: the patient's own palm with fingers is about 1% TBSA. Use it for small or scattered burns.
- Children: the head is relatively bigger and the legs smaller, so use the Lund and Browder chart, which adjusts each region for age.
- Count only partial- and full-thickness areas. Superficial (first-degree) burns are not counted.
Exam point: working out a case
S21: face, upper chest and both arms. If the whole of both arms (9 + 9), the front of the head (4.5) and the upper half of the front trunk (9) are burnt, the total is about 31.5%. Show the working; examiners give marks for the method.
By severity
A burn needs a specialist burn unit when any of these apply (classic American Burn Association referral criteria):
- Partial-thickness burns over 10% TBSA
- Any full-thickness burn
- Burns of the face, hands, feet, genitals, perineum or over major joints
- Electrical, chemical or inhalation injury
- Burns in a patient with other serious illness or injury (for example the W17 electrician with rib fractures)
3Causes and risk factors
- Kitchen burns: kerosene or gas stoves, cooking on the floor, loose synthetic clothing such as a dupatta or saree catching fire. Women are at high risk (S21 housemaid, S22 stove refuelling).
- Scalds in children from hot water, tea and milk.
- Firecrackers around festivals (W16 boy).
- Electrical injury in electricians and linemen (W17, W20).
- Chemical burns at work, and acid attacks.
- Higher risk with epilepsy, alcohol use, old age and young childhood, crowded housing and poor fire safety.
4Pathophysiology to impairments
Papers ask "discuss the impairments with clinical reasoning" (W22). This chain is that reasoning.
Local wound: Jackson's three zones
- Zone of coagulation (centre): tissue is dead and cannot recover.
- Zone of stasis (around it): blood flow is reduced. It can recover with good resuscitation, or die if the patient is under-resuscitated or infected.
- Zone of hyperaemia (outer): increased blood flow. Usually recovers fully.
Whole-body effects
- Capillary leak: fluid and protein leak out of vessels, so the tissues swell and blood volume falls. In large burns (over about 20% TBSA) this causes burn shock in the first 24–48 hours.
- Hypermetabolism: the body burns energy and breaks down muscle for months, which causes weight loss and weakness.
- Lowered immunity and an open wound lead to infection and sepsis.
- Inhalation injury: heat swells the upper airway; smoke chemicals damage the lower airways and alveoli; carbon monoxide and cyanide poison oxygen delivery.
Healing causes the long-term problems
Deep burns heal with scar. Cells in the scar called myofibroblasts pull the wound edges together. Scar keeps contracting for months, so it pulls joints into the position of comfort, which is usually flexion and adduction. This is why the position of comfort is the position of contracture.
From burn to the problems physio treats
Text version (write this as the answer)
- Heat, electricity or chemicals kill skin and deeper tissue.
- Capillary leak causes oedema and, in large burns, burn shock.
- Hypermetabolism breaks down muscle; immunity falls, so infection risk rises.
- Inhaled smoke causes airway oedema, lung damage and carbon monoxide poisoning.
- Deep burns heal by scar, and the scar keeps contracting for months.
- Impairments: pain, reduced range and contracture with hypertrophic scar; weakness, low endurance and reduced ADL; reduced ventilation with retained secretions.
- Physiotherapy: positioning, splinting, range of motion and scar care; early mobilisation and graded exercise; breathing exercises, airway clearance and upright positioning.
Stages of wound healing (3 marks in S19; 3 marks inside W22)
| Stage | When | What happens |
|---|---|---|
| 1. Haemostasis | Minutes to hours | Vessels constrict, platelets form a clot, which releases growth factors |
| 2. Inflammation | About days 1–5 | Neutrophils and macrophages clean the wound; redness, heat, swelling, pain |
| 3. Proliferation | About day 4 to week 3 | Granulation tissue, new vessels, collagen laid down, epithelium covers the wound, wound contracts |
| 4. Remodelling (maturation) | Week 3 to 1–2 years | Collagen is reorganised and strengthened; scar flattens and fades. Scar is never as strong as normal skin. |
Factors affecting wound healing (7 marks in S25)
| Type | Factors that slow healing |
|---|---|
| Local (in the wound) | Infection; poor blood supply (arterial disease, pressure, tight dressings); oedema; dead tissue or foreign bodies; repeated shear, friction or pressure; a wound that is too dry or too wet; a large or deep wound; previous radiotherapy |
| General (in the patient) | Older age; poor nutrition (protein, vitamin C, zinc); diabetes with high sugar; smoking; anaemia and low oxygen; obesity; drugs (steroids, chemotherapy); kidney or liver failure; reduced immunity; stress and poor sleep |
The modalities that help healing (S24, S25) are on the diabetes and wound page.
Recall check. Write the three zones of Jackson, the four stages of wound healing and five factors that slow healing from memory.
5Clinical features
- Burn wound appearance by depth (see section 2).
- Pain: severe in superficial partial thickness; less in deep burns.
- Swelling peaks around 24–48 hours, especially in the hands, face and neck.
- Circumferential deep burns of the chest can restrict breathing; on a limb, they can cut off circulation.
- Fever, fast heart rate and fast breathing from hypermetabolism.
Suspect inhalation injury when
- The burn happened in a closed space (kitchen, room, vehicle).
- There are burns of the face and neck, singed nasal hair or eyebrows, or soot in the mouth or nose.
- Sputum is black (carbonaceous).
- The voice is hoarse, or there is stridor, wheeze or breathlessness.
- The patient is confused or drowsy (carbon monoxide).
Airway swelling can worsen over the first day, so these patients are watched closely and often intubated early.
Electrical burns
- Entry and exit wounds can look small while muscles along the current's path are badly damaged.
- Risks: heart arrhythmias, compartment syndrome, kidney damage from muscle breakdown (dark urine from myoglobin), nerve damage, and fractures from falls or strong muscle contraction.
6Investigations
| Test | What it shows | Physio meaning |
|---|---|---|
| TBSA and depth chart | Extent and depth of the burn | Shows which joints are at risk of contracture |
| ABG with carboxyhaemoglobin | Oxygenation, CO level, acidosis | Pulse oximeter SpO₂ can read falsely normal in CO poisoning. Use the blood gas. |
| Chest X-ray | Often normal at first; later collapse, pneumonia or ARDS | Guides airway clearance and positioning |
| Bronchoscopy | Soot and airway damage in inhalation injury | Confirms the need for intensive chest physiotherapy |
| ECG, CK, urine myoglobin | Arrhythmia and muscle damage after electrical injury | Mobilise only when the heart is stable |
| Haemoglobin, electrolytes, albumin, wound swabs | Blood loss, fluid balance, nutrition, infection | Low haemoglobin or infection limits exercise tolerance |
7Medical and surgical management
First aid
- Stop the burning: remove the person from the source, take off burnt clothing and jewellery.
- Cool the burn under cool running water for 20 minutes. Do not use ice, toothpaste or butter.
- Cover with clean cling film or a clean cloth; keep the patient warm.
Hospital care
- Airway and breathing first; early intubation if inhalation injury is suspected; high-flow oxygen for CO poisoning.
- Fluid resuscitation for large burns (about 20% TBSA or more in adults), guided by urine output.
- Pain relief, tetanus cover, high-protein and high-calorie feeding.
- Wound care: cleaning, dressings (for example silver-based dressings), and daily review.
- Escharotomy: cutting through tight full-thickness eschar on the chest or a limb to free breathing or circulation. Fasciotomy if a compartment is tight.
- Early excision and grafting: dead tissue is removed and the wound is covered, usually with a split-thickness skin graft taken from a donor site such as the thigh. Grafts may be meshed to cover a larger area. Full-thickness grafts and flaps are used for the face, hands and joints.
- Later reconstruction: contracture release, Z-plasty and further grafts.
Classic answer vs current guideline: fluid formula
Classic (Parkland formula)
4 mL × body weight (kg) × %TBSA of Ringer's lactate in 24 hours. Half in the first 8 hours from the time of the burn, half over the next 16 hours.
Current (American Burn Association)
Start lower, at 2 mL/kg/%TBSA, and adjust the rate to keep urine output around 0.5 mL/kg/hour in adults. Giving too much fluid causes swelling, compartment syndrome and lung problems.
Write in the exam
"Parkland formula 4 mL/kg/%TBSA, half in 8 hours; current guidance starts at 2–4 mL/kg/%TBSA and titrates to urine output 0.5 mL/kg/h."
8Complications and prevention
| Complication | What to look for | Physio role |
|---|---|---|
| Contractures | Loss of range across burnt joints, especially neck, axilla, elbow, hand, knee, ankle | Prevent from day 1: anti-deformity positioning, splints, regular stretching and ROM |
| Hypertrophic scar and keloid | Raised, red, itchy, tight scar within the wound (hypertrophic) or spreading beyond it (keloid) | Pressure garments, silicone, massage, stretching |
| Chest problems: pneumonia, collapse, ARDS | Rising breathing rate, falling oxygen, fever, crackles | Upright positioning, deep breathing, airway clearance, early mobilisation |
| Infection and sepsis | Fever, wound changes, confusion, low BP | Strict hand hygiene and gowns; report changes |
| Heterotopic ossification (bone in soft tissue, commonest at the elbow) | Painful, warm joint with sudden loss of range | Active, gentle movement; avoid forceful passive stretching of that joint |
| Compartment syndrome | Tight, very painful limb, pain on passive stretch, numbness | Elevate limbs; report urgently |
| Exposed tendon injury, especially the finger extensor hood (boutonnière deformity) | Tendon visible in the wound over the finger joints | Protect: splint the finger straight; avoid combined finger flexion |
| Weakness, deconditioning, pressure sores, DVT | Long bed rest, weight loss | Early walking, strengthening, turning schedule, ankle pumps |
| Nerve damage and neuropathy | Numbness, weakness (common after electrical burns) | Protect numb areas; strengthen; splint if needed |
| Psychological problems | Anxiety, low mood, nightmares, body-image distress | Encourage, set achievable goals, refer for counselling |
| Marjolin's ulcer (late) | A non-healing ulcer in an old burn scar, years later | Teach skin checks; refer any non-healing scar ulcer |
9PT assessment
Subjective
- How, when and where the burn happened: closed space? electrical? first aid given?
- Pain (rest, movement, dressings), itching, breathlessness, cough and sputum.
- Surgery done or planned: grafts and donor sites, escharotomy.
- Social history (fills the ICF): occupation and hand dominance, earning role, children at home, house type, toilet, family support.
- Patient's goals and fears, including appearance.
Objective
- Vital signs: HR, BP, RR, temperature, SpO₂ (remember the CO caution).
- Chest: breathing pattern, chest expansion (eschar may restrict it), auscultation, cough and sputum.
- Burn chart: sites, depth, TBSA, areas crossing joints, grafts and donor sites.
- Oedema of the hands, face and limbs.
- ROM with a goniometer (active first; passive only where allowed), muscle strength, sensation.
- Function: bed mobility, transfers, walking, self-care, hand function.
- Scar (rehabilitation phase): height, flexibility, colour and blood supply.
| Measure | What it tells you |
|---|---|
| Vancouver Scar Scale | Scar pigmentation, vascularity, pliability and height |
| POSAS (Patient and Observer Scar Assessment Scale) | Scar quality from both the patient's and the therapist's view, including itch and pain |
| Goniometry | Range at each burnt joint |
| Burn Specific Health Scale – Brief | Burn-specific quality of life |
| Pain (VAS or NRS), grip strength, 6-minute walk test, Barthel or FIM | Pain, hand strength, endurance and independence |
10PT diagnosis by ICF
Draw the six-box ICF model first (it is drawn on the IHD page), then fill it from the case.
Worked example from a real paper (S21, 6 + 6 + 3 marks)
"35 year old housemaid suffered accidental stove burns 3 days back affecting her upper chest, face & bilateral upper limbs. Discuss her ICF & PT management. Write the Wallace's Rule of Nine."
Spot the ICF clues before you write
housemaid means heavy two-handed work: participation. 3 days back means the emergent-to-acute phase, with swelling and a fluid shift. face plus a stove fire in a kitchen raises the question of inhalation injury. bilateral upper limbs means both hands may be involved, so self-care is affected.
| ICF component | From this case | Clinical reasoning |
|---|---|---|
| Health condition | Thermal (flame) burns of the face, upper chest and both upper limbs, day 3; about 30% TBSA if all of the face, upper chest and both arms are burnt; depth to be charted | Day 3: oedema is at its peak; grafting may follow |
| Body structure | Skin loss over face, anterior chest, axillae, elbows, wrists and hands | Burns crossing flexor surfaces will contract |
| Body function impairments |
|
|
| Activity limitations | Feeding, washing, dressing, grooming and toileting (both hands); reaching overhead; lifting; walking long distances | Both hands affected, so she cannot compensate with one hand |
| Participation restrictions | Cannot work as a housemaid (sweeping, washing clothes and vessels, cooking); family roles; social life | Housework needs repeated gripping and reaching, which are lost |
| Environmental factors | Barriers: loss of daily wage, cooking on a stove at floor level, likely Indian toilet. Facilitators: burn unit care, family support (to be asked). | Barriers become education goals (kitchen safety, return-to-work plan) |
| Personal factors | 35-year-old woman; manual worker; possible distress about facial scarring | Young, so good potential; psychological support affects adherence |
One-line functional diagnosis
A 35-year-old housemaid, day 3 after flame burns of the face, upper chest and both upper limbs, with pain, oedema and risk of neck, axillary, elbow and hand contractures and reduced chest expansion. These limit self-care, reaching and gripping, and restrict her work and family roles. Burn-unit care is a facilitator; loss of daily wages is a barrier.
Recall check. Fill the six ICF boxes for the W22 case in the exam corner (40% burns of both thighs and legs).
11Problem list and goals
| Problem | Short-term (2–3 weeks) | Long-term (3–6 months and beyond) |
|---|---|---|
| Breathing | Clear chest, normal SpO₂ on air, effective cough | Normal chest expansion |
| Oedema and pain | Hand oedema reduced; pain controlled for exercise | Pain-free daily activity |
| Range of motion | Maintain full neck extension, shoulder abduction, elbow extension and hand range; no contracture | Full functional range; mouth opening normal |
| Scar | Wounds closed; grafts taken | Flat, pliable scar using pressure garment and silicone |
| Function | Independent feeding, washing face, toileting | Full self-care; return to housework and paid work |
| Prevention and coping | Understands positioning and splint schedule | Practises kitchen fire safety; coping with appearance |
12PT management
Write it phase by phase. Papers ask for short-term and long-term management, which map onto these phases.
Phase 1: emergent or resuscitative (first 72 hours)
- Respiratory care: head of bed raised (sit up at least 30°), deep breathing, thoracic expansion exercises, ACBT, assisted cough, suction if needed. If ventilated: positioning, secretion clearance, manual techniques where skin allows.
- Oedema control: elevate burnt limbs above the heart (hands on pillows or slings), with active finger and ankle exercises.
- Positioning and splinting in anti-deformity positions from day 1 (table below).
- Range of motion: active exercises of every burnt joint, about every hour while awake. Use passive or active-assisted movement if the patient cannot move. Give analgesia before sessions.
- Mobility: sitting out and walking as soon as the patient is stable.
Phase 2: acute (until the wounds are closed)
- Continue ROM, positioning and splinting. Time exercise with dressing changes, when the wound is visible and analgesia is given.
- After skin grafting: immobilise the grafted area, usually for about 3–5 days (the surgeon decides). Keep moving all other joints. Then restart gentle active ROM over the graft. Avoid friction and shear on new grafts.
- Donor sites (often the thigh) hurt but can usually be moved early.
- Lower-limb burns or grafts: wrap the leg in a compression bandage before standing, because dependent legs swell and grafts can fail.
- Strengthening, walking, and self-care training (eating, washing) with built-up handles if grip is weak.
Phase 3: rehabilitation (after wound closure, while scar matures over 1–2 years)
- Stretching: slow, sustained stretches across scar until it blanches, held 20–30 seconds or longer, several times a day.
- Scar management: pressure garments, silicone gel sheets, scar massage once the skin is strong enough, moisturising.
- Splints: night splints to hold gains; dynamic splints or serial casting for established contractures.
- Strength and endurance: progressive resistance, aerobic training, hand therapy, fine motor practice.
- Return to work: work-specific tasks, graded loading of the hands, sun protection outdoors.
- Psychological support and peer support; cosmetic camouflage advice.
Anti-deformity positioning (7 marks in S17 and W18; part of S16)
Memory hook
Position of comfort = position of contracture
Burns pull joints into flexion and adduction. So position the opposite way: stretch the burnt surface.
| Burnt area | Tends to contract into | Position or splint in |
|---|---|---|
| Anterior neck | Flexion | Neck extension: no pillow, small roll under the shoulders; neck conformer collar |
| Axilla and shoulder | Adduction, internal rotation | Shoulder abduction about 90° with slight forward flexion (about 15°) to protect the brachial plexus; axillary ("aeroplane") splint |
| Front of elbow | Flexion, pronation | Elbow extension, forearm neutral or supinated |
| Back of hand | Claw: MCP extension, IP flexion, thumb adduction | Safe position ("intrinsic plus"): wrist extended about 20–30°, MCP joints flexed about 70–90°, finger joints straight, thumb abducted |
| Palm | Finger and thumb flexion | Fingers and thumb extended (palm stretched out) |
| Chest and trunk | Forward flexion, rounded shoulders | Lie flat, trunk extended, shoulders back |
| Hip and groin | Flexion, adduction | Hip extension, slight abduction (about 10–20°), neutral rotation; prone lying when allowed |
| Back of knee | Flexion | Knee extension; no pillow under the knee |
| Ankle | Plantarflexion (foot drop) | Ankle neutral (90°); ankle–foot splint |
| Face and mouth | Small mouth (microstomia), eyelid pulling | Mouth-stretching exercises, mouth splint; no pillow pressing on burnt ears |
Directions are standard in all burn rehabilitation texts. Angles are typical values; they vary slightly between units.
Splints (S19: three splints with their purpose)
| Splint | Purpose |
|---|---|
| Resting hand splint in the safe position | Prevents claw hand after dorsal hand burns; protects the extensor tendons |
| Neck conformer (soft collar) | Keeps the neck extended; prevents neck flexion contracture |
| Axillary (aeroplane) splint | Holds the shoulder abducted; prevents axillary contracture |
| Elbow and knee extension splints | Hold extension across flexor-surface burns |
| Ankle–foot splint | Holds the ankle at 90°; prevents foot drop and heel pressure sores |
| Mouth splint | Stretches the mouth; prevents microstomia |
| Dynamic splints and serial casts (later) | Gradually stretch established contractures |
Role of splinting (S18): splints hold the anti-deformity position when the patient cannot, protect exposed tendons and new grafts, and keep the range gained by exercise. In the acute phase they are worn at rest and at night and removed for exercise. Check them daily for pressure and fit, because swelling changes.
Inhalation burns (7 marks in W22)
- Upright positioning to reduce airway swelling and help breathing.
- Humidified oxygen; high-flow oxygen for carbon monoxide.
- Deep breathing, ACBT, huffing, assisted cough, suction. Mobilise early.
- If ventilated: regular repositioning, airway clearance, careful bagging with suction.
- Watch for worsening: stridor, rising breathing rate, falling oxygen. Call the team early.
Lower-limb burns (7 marks in W25; long cases W22 and S24)
| Depth | What to expect | Physiotherapy |
|---|---|---|
| Superficial and superficial partial-thickness | Heal on their own in about 1–3 weeks; painful; little scarring | Elevate the leg; ankle pumps and active hip, knee and ankle movement every hour; walk early, with a compression bandage if the leg swells when down; moisturise once healed |
| Deep partial and full-thickness | Need grafting; risk of hip and knee flexion and ankle plantarflexion contractures, oedema, DVT and heel pressure sores | Hip extension with slight abduction, knee straight, ankle at 90°; knee extension splint and ankle–foot splint; elevation; heels off the bed. After grafting, rest the grafted area as the surgeon advises, then start standing and walking in a compression bandage, with a walking aid if needed. Later: stretches of hip flexors, hamstrings and calf; strengthening of quadriceps, glutes and calf; pressure garments; stairs and work tasks |
Deep burns all the way round a limb can tighten like a band and cut off the blood supply. Check toe colour, warmth and pulses, and report quickly (the surgeon may release the eschar).
Burns in pregnancy (S24: full-thickness burns of the right leg, 6 months pregnant)
There are two patients: the mother and the baby. The baby does well only if the mother's oxygen, blood pressure and nutrition stay good, so involve the obstetric team and report any warning sign at once.
- Position: from about 20 weeks, do not leave her flat on her back, because the uterus presses on the inferior vena cava and lowers her blood pressure. Use left side-lying or a wedge under the right hip (left tilt). With a right-leg burn, left side-lying also keeps the burnt leg on top, supported on pillows with the knee straight and the ankle at 90°.
- DVT: pregnancy, burns and bed rest all raise the risk. Ankle pumps and active exercise of the good leg every hour, early walking, and anticoagulants as prescribed.
- Chest: the uterus pushes the diaphragm up, so lung volumes fall. Deep breathing and thoracic expansion in side-lying or sitting.
- Burnt leg: the same lower-limb plan as above, but no electrotherapy or heat over the abdomen, pelvis or lower back, and no shortwave diathermy.
- Exercise: moderate effort, avoid breath-holding and straining. Stop and report bleeding, abdominal pain, contractions, leaking fluid or reduced baby movements.
- Emotional support: she is crying and afraid for her baby. Explain each step, give treatment after analgesia, and involve her family.
By impairment (for "physiotherapy for each impairment", W22)
| Impairment | Technique and dose | Why |
|---|---|---|
| Pain | Exercise after analgesia; explain each step; relaxation and distraction | Pain is the main reason patients stop moving |
| Oedema | Elevate limbs above the heart; active pumping exercises 10 repetitions every hour; compression wraps before standing | Muscle pump and gravity move fluid back |
| Contracture risk, reduced ROM | Anti-deformity positioning, splints; active ROM of every burnt joint hourly; sustained stretches in rehab | Holds scar in its lengthened position while collagen is laid down |
| Reduced chest expansion, secretions | Deep breathing, thoracic expansion, ACBT, assisted cough, upright sitting | Prevents collapse and pneumonia |
| Weakness and low endurance | Early sitting and walking; progressive resistance; aerobic exercise in rehab | Counters hypermetabolic muscle loss and bed rest |
| Hypertrophic scar | Pressure garment about 23 hours a day; silicone sheets; massage; moisturiser | Pressure and hydration flatten and soften scar |
| Reduced function | ADL training, adapted handles, work-specific practice | Restores independence and return to work |
Classic answer vs current evidence: pressure garments
Classic
Every deep burn gets a custom pressure garment, worn about 23 hours a day at about 20–25 mmHg, for 12–18 months until the scar matures.
Current (Cochrane 2024)
Still standard practice, but the evidence that garments improve scars is very uncertain. Comfort and wearing them regularly matter. Silicone and massage are used alongside.
Write in the exam
"Pressure garment therapy about 23 hours a day for 12–18 months, with silicone gel and scar massage."
Electrotherapy for wound healing (S16, S22) is covered on the diabetes and wound-healing page.
Recall check. Without looking, write the anti-deformity position for the neck, axilla, back of the hand and ankle.
13Precautions, contraindications and stop criteria
Take care
- Fresh grafts: no movement of the grafted area until the surgeon allows; no shearing or friction.
- Exposed tendons: no aggressive or combined stretching; splint the finger straight over an exposed extensor hood.
- Heterotopic ossification: no forceful passive movement of a hot, painful, stiffening joint.
- Haemodynamic instability in the first days: keep exercise gentle and monitored.
- CO poisoning: pulse oximetry can be falsely normal.
- Electrical burns: check ECG monitoring and cardiac stability before mobilising.
- Infection control: wash hands, wear gloves and a gown, clean equipment between patients.
- Associated injuries: fractures, rib fractures and head injury (W17 case) change the plan.
Stop and report if
- Breathing becomes harder, stridor appears, or oxygen falls
- Blood pressure falls, or the heart rate becomes fast or irregular
- A graft bleeds, lifts or shears
- A limb becomes tight, numb or very painful
14Education, lifestyle and home programme
Do's and don'ts for the patient
- Do your stretches and exercises several times every day, even after discharge. Scar keeps tightening for 1–2 years.
- Wear your splints and pressure garments as advised. Wash garments daily; get them refitted when they loosen.
- Moisturise healed skin and massage the scar several times a day.
- Protect healed skin from the sun with clothing and sunscreen; new skin burns and darkens easily.
- Do not scratch itchy scars. Use moisturiser, cool compresses and medicines the doctor gives.
- Protect numb areas from heat and injury.
- Report any blister, wound or ulcer in a scar that does not heal.
Preventing burns at home
- Cook on a raised platform, not on the floor. Never refuel a lit stove.
- Wear close-fitting cotton clothes while cooking; tuck in the dupatta or saree end.
- Keep children away from the kitchen, hot liquids and firecrackers.
- Know first aid: stop, drop and roll; cool running water for 20 minutes.
15Prognosis and discharge criteria
Prognosis is worse with larger TBSA, deeper burns, older age and inhalation injury. The revised Baux score estimates risk of death as age + %TBSA + 17 if there is an inhalation injury.
Discharge from the burn unit: wounds healed or manageable at home; independent or supported self-care and walking; family taught positioning, splints, exercises and skin care; follow-up arranged for scar and contracture review.
16Exam corner
Past questions (MUHS, 2016–2026)
- S16 Q4(a), 5 + 5 + 5 marks30-year-old man, 60% burns of neck, chest and both arms, in ICU. Functional diagnosis; physiotherapy; role of positioning and splinting.
- W16 Q4(a), 5 + 5 + 5 marks13-year-old boy, firecracker explosion: inhalation burns and 30% partial-thickness burns of the neck, chest and hand. Functional diagnosis, short- and long-term management.
- W17 Q3(a), 5 + 5 + 5 marks30-year-old electrician, electrical burns 2 days ago and a fall from height; 3 right ribs fractured; unconscious and ventilated. Impairments, activity and participation, short-term management.
- W20 Q4(b), 5 + 5 + 5 marks22-year-old electrician, 30% mixed burns of the right upper limb and front of the chest from wiring; in the burn unit, stable. ICF, short- and long-term management.
- S21 Q4(a), 6 + 6 + 3 marksThe worked example in section 10.
- S22 Q3(b), 15 marks35-year-old man, inhalation burns while refuelling a stove; deep partial-thickness burns of the right arm, front and back of the trunk, side of the neck, right face and thigh. Functional diagnosis, goals and management in detail.
- W22 Q3(b), 5 + 7 + 3 marks23-year-old mother of a young child, 40% burns of both thighs and legs. Impairments with clinical reasoning; physiotherapy for each impairment; stages of wound healing.
- W19 Q4(a), 5 + 5 + 5 marks12-year-old boy, 40% electrical burns of the face, neck, front of the chest and right arm from a live wire; medically stable in the burns ward. Functional diagnosis; short- and long-term physiotherapy.
- W21 Q4(b), 15 marks25-year-old fashion designer, full-thickness burns of the face, neck and chest 2 days ago; difficulty breathing; swollen face. Likely complications; functional diagnosis; management.
- S24 Q4(b), 15 marks35-year-old clerk, full-thickness burns of the right leg from thigh to foot 3 days ago; 6 months of amenorrhoea (she is pregnant); crying and not moving the limb. Functional diagnosis and management. See "Burns in pregnancy" in section 12.
- W24 Q4(b), 15 marks12-year-old boy, superficial partial-thickness burns of both arms and the front of the trunk 2 days ago; pain VAS 6/10 at rest; cannot turn or move his limbs. Functional diagnosis and management.
- S26 Q4(b), 15 marks (three parts)25-year-old woman, hot-water burns of the left arm, chest and neck, treated with closed dressings; complains of pain. (i) Extent of the burns; (ii) impairments using ICF; (iii) short- and long-term physiotherapy.
- 7-mark questionsDeformities in burns and anti-deformity positioning (S17). Classification of burns and common deformities (W17). Role of splinting (S18). Positioning to prevent deformities (W18). Management after skin grafting (S20). Inhalation burns and management (W22). Modalities for wound healing (S24). Factors affecting wound healing, with the modalities used (S25). Physiotherapy for superficial and deep burns of the lower limb (W25).
- 3-mark questionsDeep partial-thickness burns (W16). Rule of nine (W18). Three splints with their purpose (S19). Stages of wound healing (S19). Superficial burns (S20). Define inhalation burns (S24). Three complications of inhalation burns (S25).
Technique cards for this topic: suctioning, oxygen therapy, ICU physiotherapy, positioning, electrotherapy.
Keywords to underline
TBSA rule of nines depth inhalation injury oedema anti-deformity positioning position of comfort is position of contracture splinting graft immobilisation hypertrophic scar pressure garment emergent, acute, rehabilitation phase
Answer skeleton: any burns long answer
- Restate the case: age, job, cause, sites, %TBSA (work it out), depth, day, inhalation or electrical injury.
- [ICF, 5–6] ICF diagram filled from the case; one-line functional diagnosis; reasons for each impairment.
- [Short-term, 5] Emergent and acute phase: respiratory care, oedema control, anti-deformity positioning table, splints, hourly ROM, graft precautions, early mobilisation.
- [Long-term, 5] Rehabilitation phase: stretching, scar management, strengthening, hand therapy, ADL and return to work, psychological support, prevention.
- [Add-on, 3] Rule of nines, wound-healing stages or splints, whichever is asked.
Draw these
- The rule of nines figure (section 2)
- The burn-depth skin diagram (section 2)
- The ICF model, filled from the case (IHD page, section 10)
Viva questions
- Why is a full-thickness burn painless?
- What are the signs of inhalation injury?
- Why can SpO₂ be misleading after a smoke inhalation?
- What is the safe position of the hand, and why?
- How long do you immobilise a fresh skin graft?
- What is the Parkland formula, and what does current guidance change?
Test yourself
Answer on paper first, then open the answer.
3 mWrite the rule of nine.
Head and neck 9%; each upper limb 9%; front of trunk 18%; back of trunk 18%; each lower limb 18%; perineum 1%. Total 100%. Draw the front and back figure.
3 mCharacteristics of deep partial-thickness burns.
- Reaches the deep dermis.
- Blotchy red and white, drier, blisters may be absent; slow or no blanching.
- Less painful than superficial partial thickness; pressure is felt.
- Heals in more than 3 weeks with a high risk of hypertrophic scar; often needs grafting.
7 mPositioning strategies to prevent deformities in burns.
Principle: the position of comfort is the position of contracture, so stretch the burnt surface. Then write the anti-deformity table: neck extension, shoulder abduction about 90°, elbow extension, safe hand position, hip extension with slight abduction, knee extension, ankle at 90°, mouth stretching. Add splints, the wearing schedule (rest and night, off for exercise) and daily checks.
LAQW22: 23-year-old mother, 40% burns of both thighs and legs. List the impairments with clinical reasoning.
- Pain: exposed nerve endings in partial-thickness burns.
- Oedema of the legs: capillary leak; worse when the legs hang down.
- Risk of hip flexion, knee flexion and ankle plantarflexion contractures: position of comfort and scar contraction.
- Reduced walking and standing tolerance: pain, oedema, weakness; grafts on the legs need compression before standing.
- Risk of DVT and pressure sores: bed rest.
- Weakness and fatigue: hypermetabolism.
- Participation: cannot care for her young child or do housework; anxiety about appearance.
MCQA patient with dorsal hand burns should be splinted with:A. Wrist flexed, fingers flexedB. Wrist extended, MCP joints flexed, finger joints straight, thumb abductedC. Wrist neutral, all finger joints straightD. Hand in a fist around a roll
B. This "safe position" keeps the collateral ligaments of the MCP joints stretched and protects the extensor tendons over the PIP joints.
MCQAfter a kitchen fire, a patient's SpO₂ reads 99% but he is confused and has soot in his nose. What is the best next step?A. Reassure; oxygenation is normalB. Arterial blood gas with carboxyhaemoglobinC. Start a 6-minute walk testD. Begin chest percussion
B. Carbon monoxide makes the pulse oximeter read falsely high. A blood gas measures carboxyhaemoglobin directly.
MCQA split-thickness skin graft was placed over the elbow yesterday. What should physiotherapy do for that elbow?A. Full passive stretching twice dailyB. Keep it immobilised as the surgeon advises, and exercise other jointsC. Resisted elbow flexionD. Massage the graft
B. A new graft needs a few days without movement or shear to "take". Movement restarts after the surgeon clears it, usually around day 3–5.
Last recall check. Write the burn depth table, the rule of nines and four anti-deformity positions. Then check them against this page.
Sources
Notes written in original words. Diagrams drawn for this site. Numbers were checked against the sources below.
- MUHS BPTh syllabus (2012), Cardio-Vascular & Respiratory Physiotherapy. muhs.ac.in
- MUHS IV BPTh question papers, code 51413, Summer 2016 to Summer 2026: muhsonline.com (unofficial archive, 2016–2022) and the Dhole Patil College of Physiotherapy past-paper page (2019–2026)
- ISBI Practice Guidelines Committee. ISBI Practice Guidelines for Burn Care. Burns 2016;42:953–1021; Part 2, Burns 2018;44:1617–1706.
- American Burn Association guidance on fluid resuscitation, as summarised in American Family Physician 2025.
- Cochrane Review: Pressure garment therapy for preventing hypertrophic scarring after burn injury (CD013530).
- Early mobility after lower-limb split-thickness skin grafts: burn-unit protocols reporting immobilisation for about 3–5 days (conference abstract, J Burn Care Res 2025).
- Dewey WS, Richard RL, Parry IS. Positioning, splinting, and contracture management. Phys Med Rehabil Clin N Am 2011.
- Osler T, et al. Simplified estimates of the probability of death after burn injuries: extending and updating the Baux score. J Trauma 2010.
- Structure and classical content: Frownfelter & Dean, Cardiovascular and Pulmonary Physical Therapy, 6th ed. (2022); Main & Denehy, Cardiorespiratory Physiotherapy, 5th ed. (2016); Cash's Textbook of General Medical and Surgical Conditions for Physiotherapists.
Educational notes for exam preparation. Not medical advice. Hospital protocols and the treating doctor's instructions come first.
Version 1. Content checked 19 October 2026. Next review October 2027.