Integumentary: Wounds, Burns and Skin
Skin is the organ a physical therapist sees first and touches most, and wound and burn care sits squarely inside physical therapist practice: debridement, dressings, offloading, positioning and scar control. Exam questions in this area test whether you can name a wound from its location and appearance, stage it correctly, match a dressing to the wound bed, and protect a burned patient from contracture. Get these patterns right and you will also prevent the pressure injuries that start in every hospital bed.
By the end of this chapter you can
- Describe the epidermis, dermis and hypodermis and explain how depth of injury predicts healing.
- Outline the inflammatory, proliferative and remodeling phases of healing and list factors that delay them.
- Document a wound: size, undermining and tunneling, tissue type, exudate, edges and periwound skin.
- Stage a pressure injury with current terminology and use the Braden scale to target prevention.
- Differentiate arterial, venous and neuropathic wounds by location, appearance and treatment.
- Choose between selective and nonselective debridement and match dressings to moisture balance.
- Classify burn depth, estimate size with the rule of nines, and position to prevent contracture.
- Recognize the ABCDE warning signs of melanoma and common skin infections that require referral.
Section 1Skin structure and wound healing
The layers of the skin
The epidermis is avascular stratified squamous epithelium, about 0.05 to 1.5 mm thick, nourished by diffusion from the dermis. From deep to superficial its layers are the stratum basale (dividing keratinocytes, melanocytes and Merkel cells), stratum spinosum (with Langerhans immune cells), stratum granulosum, stratum lucidum (only in thick skin of the palms and soles) and stratum corneum, dead keratinized cells that form the main water barrier. Keratinocytes move from basale to corneum in about 4 weeks.
The dermis is the vascular, innervated connective tissue layer. The thin papillary dermis interlocks with the epidermis through rete ridges, which resist shear; it holds capillary loops and touch receptors (Meissner corpuscles). The thick reticular dermis is dense type I collagen and elastin with deeper vessels, Pacinian corpuscles, sweat glands and hair follicles. Hair follicles and sweat glands are lined with epithelial cells, so when the epidermis is lost but these appendages survive, new epithelium grows up from them as well as in from the edges. That is why partial thickness wounds heal by regeneration and full thickness wounds heal by scar. The hypodermis (subcutaneous tissue) is fat and loose connective tissue that insulates and cushions.
Skin functions are protection, thermoregulation (sweating and vasomotor control), sensation, vitamin D synthesis, immune surveillance and fluid retention. Aging thins the epidermis, flattens the rete ridges (so the layers shear apart easily, causing skin tears), and reduces collagen, blood flow and sensation.
Phases of wound healing
Healing proceeds through overlapping phases.
| Phase | Typical timing in an acute wound | Key cells and events | What you see |
|---|---|---|---|
| Hemostasis and inflammation | Immediately to about day 4 to 6 | Platelets form a clot and release growth factors; neutrophils clean bacteria; macrophages (the key cell) remove debris and signal repair | Redness, heat, swelling, pain; serous drainage |
| Proliferation | About day 3 to week 3 | Fibroblasts lay down type III collagen; angiogenesis forms granulation tissue; myofibroblasts pull the edges in (contraction); keratinocytes migrate across (epithelialization) | Beefy red, moist, bumpy granulation; pink new epithelium at the edges |
| Maturation (remodeling) | About day 21 to 2 years | Type III collagen replaced by stronger type I, fibers realign along stress lines | Scar flattens and pales; reaches only about 80% of original tensile strength |
Wounds close by three routes. Primary intention: edges are approximated (sutures, staples), so healing is fast with minimal scar. Secondary intention: the wound is left open and fills with granulation tissue, contracts and epithelializes; this is how most chronic wounds heal. Delayed primary (tertiary) intention: a contaminated wound is left open for several days, then closed. A chronic wound is one that fails to progress through the phases in an orderly way, often stuck in inflammation, and has not reduced meaningfully in size after about 4 weeks of good care.
Factors that delay healing
- Local: inadequate perfusion and oxygen, infection and biofilm, necrotic tissue, too much or too little moisture, unrelieved pressure or shear, edema, foreign bodies, repeated trauma, and a cold wound bed (dressing changes that cool the wound slow cell activity).
- Systemic: older age, diabetes (impaired neutrophil function and microvascular disease), poor nutrition (protein in particular), anemia, smoking (vasoconstriction and carbon monoxide), obesity, immunosuppression, corticosteroids (suppress inflammation and collagen synthesis), chemotherapy and radiation, and renal or hepatic failure.
- Nutrition markers: commonly cited low values are serum albumin below 3.5 g/dL and prealbumin below about 15 mg/dL; prealbumin, with a half life of 2 to 3 days, reflects recent intake better, though both fall with inflammation. Protein, calories, vitamin C, zinc and hydration all matter, so refer to a dietitian.
Documenting a wound
Good documentation lets anyone see whether a wound is improving.
- Location using anatomic landmarks.
- Size: length is measured head to toe and width perpendicular to it at the widest points; depth with a sterile cotton tipped applicator at the deepest point, all in centimeters.
- Undermining (tissue loss under intact skin along the edge, a shelf) and tunneling (a narrow channel extending in one direction) are recorded with the clock method, where 12 o'clock points toward the patient's head: for example, "undermining 1.5 cm from 2 to 5 o'clock; tunnel 3 cm at 9 o'clock".
- Wound bed tissue as percentages: granulation (red), epithelial (pink), slough (yellow, tan or gray, stringy or soft), eschar (black or brown, leathery necrotic tissue).
- Exudate: amount (none, scant, small, moderate, large) and type.
- Wound edges: attached, unattached, or rolled (epibole, which halts epithelial migration and needs to be opened); periwound skin: maceration (white, soggy from moisture), erythema, induration, callus.
- Odor (assessed after cleansing), pain, and signs of infection. Standardized tools such as the PUSH tool track healing over time.
| Exudate type | Appearance | Meaning |
|---|---|---|
| Serous | Clear, thin, watery, light yellow | Normal in inflammatory phase |
| Serosanguineous | Thin, pink to light red | Normal in early healing |
| Sanguineous | Thin, bright red | Fresh bleeding, trauma to granulation tissue |
| Purulent (seropurulent) | Thick, opaque, yellow, tan or green, often odorous | Infection; report |
Reasoning: Document the shelf as undermining from 1 to 4 o'clock and the channel as a tunnel at 7 o'clock, with 12 o'clock toward the head. Corticosteroids and low prealbumin both slow healing, so the best plan includes a dietitian referral and communication with the physician, not only local care. A tempting choice is to call the channel "undermining"; undermining runs along the edge across a span of clock hours, while a tunnel is a narrow track in one direction. Safety point: tunnels must be filled loosely, never packed tight, and probed gently to avoid creating false tracts.
The avascular epidermis sits on the vascular dermis, whose surviving hair follicles and sweat glands let partial thickness wounds regenerate. Healing runs through inflammation, proliferation (granulation, contraction, epithelialization) and years of remodeling, and scar never regains full strength. Local factors (perfusion, infection, moisture, pressure) and systemic factors (diabetes, steroids, nutrition, smoking) decide whether a wound moves forward. Document size head to toe, undermining and tunneling by the clock, tissue percentages, exudate, edges and periwound skin.
Section 2Wound types and their features
Pressure injuries
A pressure injury is localized damage to skin and underlying tissue, usually over a bony prominence or under a medical device, from intense or prolonged pressure, often combined with shear. Pressure above capillary closing pressure (classically about 32 mmHg) for long enough causes ischemia; muscle and fat are more vulnerable than skin, so damage can begin deep and work outward. Shear (skin held by friction while the skeleton slides, as when the head of the bed is raised and the patient slides down) kinks deep vessels and is typical of sacral and coccygeal injuries. Moisture from incontinence or sweat macerates skin and raises friction. Common sites: sacrum and coccyx, heels, ischial tuberosities (sitting), greater trochanters (sidelying), occiput (infants and supine patients), elbows, scapulae and malleoli.
Staging uses the system of the National Pressure Injury Advisory Panel. Stage describes the deepest tissue layer exposed.
| Category | Definition | Notes |
|---|---|---|
| Stage 1 | Intact skin with nonblanchable erythema | Harder to see in darkly pigmented skin; look for warmth, coolness, firmness or color change |
| Stage 2 | Partial thickness loss with exposed dermis; pink or red moist bed, or an intact or ruptured serum filled blister | No fat, slough or eschar visible; not used for moisture damage, skin tears or burns |
| Stage 3 | Full thickness skin loss; fat visible, granulation and epibole often present | Slough or eschar may be present; undermining and tunneling possible; no fascia, muscle, tendon, ligament, cartilage or bone exposed |
| Stage 4 | Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone | Undermining, tunneling and osteomyelitis risk |
| Unstageable | Full thickness loss obscured by slough or eschar so depth cannot be confirmed | Will be stage 3 or 4 once the base is seen; leave stable dry eschar on heels or ischemic limbs |
| Deep tissue pressure injury | Intact or nonintact skin with persistent nonblanchable deep red, maroon or purple discoloration, or a blood filled blister | Damage at the bone muscle interface; may evolve rapidly into a full thickness wound |
Two further labels: medical device related pressure injury (shaped like the device, such as a splint, tubing or oxygen mask, and staged with the same system) and mucosal membrane pressure injury (on mucosa, not staged). Pressure injuries are never reverse staged: a stage 4 that is filling with granulation is documented as a healing stage 4, because granulation and scar are not the muscle and fat that were lost.
Risk assessment and prevention
The Braden scale scores six areas: sensory perception, moisture, activity, mobility (each 1 to 4), nutrition (1 to 4) and friction and shear (1 to 3). Totals range from 6 to 23, and lower scores mean higher risk. A score of 18 or less is generally considered at risk (15 to 18 mild, 13 to 14 moderate, 10 to 12 high, 9 or less very high). Prevention follows from the subscales:
- Reposition bed bound patients at regular intervals (every 2 hours is the traditional standard; frequency is individualized to the surface and the patient's skin response).
- Use a 30 degree tilted sidelying position rather than full sidelying over the trochanter, and keep the head of the bed at 30 degrees or less when safe to reduce shear.
- Float the heels with a pillow under the calves or a heel boot so the heel bears no weight.
- In sitting, teach pressure relief every 15 to 30 minutes (forward lean, side lean or push up held long enough to reperfuse, often cited as 1 to 2 minutes) and reposition at least hourly; use a pressure redistributing cushion; avoid donut cushions.
- Manage moisture with barrier products and incontinence care, maximize nutrition and hydration, and use lift sheets so skin is not dragged.
Vascular and neuropathic wounds
The three other classic chronic wounds are recognized by location and appearance. Chapter 9 covers the circulation problems behind arterial and venous wounds.
| Feature | Arterial | Venous | Neuropathic (diabetic) |
|---|---|---|---|
| Location | Toes, between toes, lateral malleolus, dorsum of foot, sites of trauma | Medial lower leg above the medial malleolus (gaiter area) | Plantar surface under metatarsal heads, great toe, heel, sites of shoe pressure |
| Appearance | Round, punched out, deep, pale or necrotic base, smooth well defined edges | Shallow, irregular edges, red granular base, may be large | Round, surrounded by thick callus, often deep, may probe to bone |
| Exudate | Minimal | Moderate to heavy | Variable |
| Pain | Severe, worse with elevation | Aching, better with elevation | Little or none because of sensory loss |
| Surrounding signs | Absent pulses, thin hairless shiny skin, cool, dependent rubor | Edema, hemosiderin staining, lipodermatosclerosis, dermatitis | Loss of protective sensation, dry cracked skin, foot deformity, Charcot changes |
| Core treatment | Restore blood flow (vascular referral); keep dry eschar dry; protect | Compression (after ABI check), elevation, exercise | Offloading (total contact cast), glucose control, debridement of callus |
The diabetic foot develops wounds through neuropathy (sensory loss removes the warning of pain; motor loss causes intrinsic weakness and claw toes that raise metatarsal head pressure; autonomic loss dries and cracks the skin), vascular disease and impaired immunity. Protective sensation is screened with the 5.07 (10 gram) Semmes Weinstein monofilament: inability to feel it at tested plantar sites means loss of protective sensation. The Wagner classification grades diabetic foot ulcers from 0 (intact skin, at risk) through 1 (superficial ulcer), 2 (deep to tendon, capsule or bone without abscess or osteomyelitis), 3 (deep with abscess or osteomyelitis), 4 (forefoot gangrene) and 5 (whole foot gangrene). A wound that probes to bone strongly suggests osteomyelitis. A hot, swollen, red foot with intact skin and minimal pain in a patient with neuropathy may be acute Charcot neuroarthropathy; it needs immediate immobilization and offloading, and it is often mistaken for cellulitis or DVT.
Wounds that are not pressure injuries must not be staged as such: skin tears (traumatic separation of epidermis from dermis in fragile skin), moisture associated skin damage such as incontinence associated dermatitis (diffuse, shiny, irregular, superficial, in skin folds and the perineum, without a bony prominence), and surgical wound dehiscence.
Reasoning: Plantar location, callus, and loss of protective sensation with adequate perfusion make this a neuropathic ulcer. The highest priority intervention is offloading, ideally with a total contact cast if there is no infection, plus callus debridement and glucose control. Compression wraps (a venous treatment) and leg elevation or limiting walking alone are wrong. Safety point: check for probing to bone, spreading cellulitis and a hot red foot that could be Charcot before casting.
Reasoning: Persistent nonblanchable purple or maroon discoloration of intact skin is a deep tissue pressure injury, not a stage 1 (which is red) and not a bruise to ignore. A Braden of 11 means high risk. The best actions are to float the heels completely, use a pressure redistributing surface, reposition on a schedule, and document and report. Applying a heating pad or massaging the area would harm compromised tissue. Safety point: deep tissue injuries can open rapidly into stage 3 or 4 wounds, so offloading starts at once.
Pressure injuries are staged by the deepest tissue visible: stage 1 intact and red, stage 2 dermis, stage 3 fat, stage 4 muscle, tendon or bone, with unstageable and deep tissue injury categories and no reverse staging. The Braden scale (6 to 23, at risk at 18 or less) directs prevention: turning, heel floating, 30 degree positioning and seated pressure relief. Arterial, venous and neuropathic wounds are recognized by location, appearance and pain, and each has a different core treatment: blood flow, compression or offloading.
Section 3Wound management
Wound bed preparation
Local care follows a simple sequence often summarized by the letters TIME: remove nonviable Tissue, control Infection and inflammation, restore Moisture balance, and advance the Edge (address epibole, undermining and stalled epithelium). All of it rests on treating the cause: pressure off a pressure injury, compression on a venous wound, blood flow to an arterial wound, and offloading for a neuropathic foot. Cleanse wounds with normal saline or a noncytotoxic cleanser at a pressure of about 4 to 15 psi, enough to remove debris without driving bacteria into tissue; antiseptics such as povidone iodine, hydrogen peroxide and full strength Dakin solution damage fibroblasts and are reserved for short term use in heavily contaminated wounds.
Debridement
Debridement removes necrotic tissue, slough, foreign material and biofilm, which feed bacteria and block healing. Methods are grouped as selective (remove only nonviable tissue) or nonselective (remove viable and nonviable tissue alike).
| Method | Type | How it works | Best use and cautions |
|---|---|---|---|
| Sharp (conservative sharp) | Selective | Scalpel, scissors and forceps remove loose necrotic tissue above viable tissue | Fastest; check state practice act and competence; caution with anticoagulation and low platelets; stop at bleeding or pain; not on ischemic wounds with stable eschar |
| Enzymatic | Selective | Topical collagenase digests necrotic tissue | When sharp debridement is not possible; slower; some products are inactivated by silver or iodine |
| Autolytic | Selective | The body's own enzymes liquefy necrotic tissue under a moisture retentive dressing | Painless, slow; avoid in infected wounds and immunocompromised patients; expect odor and exudate under the dressing |
| Biological (larval) | Selective | Sterile maggots digest necrotic tissue and bacteria | Effective in resistant wounds; patient acceptance varies |
| Mechanical: wet to dry gauze | Nonselective | Moist gauze dries and tears tissue off when removed | Painful, damages granulation and cools the wound; largely outdated |
| Mechanical: pulsed lavage with suction | Nonselective (low pressure) | Pressurized irrigation (about 4 to 15 psi) with suction | Good for tunnels and large necrotic wounds; use protective gear because of aerosolized spray; caution near exposed vessels, grafts and body cavities |
| Mechanical: whirlpool | Nonselective | Agitated water softens and loosens debris | Now rarely used; risks cross contamination, maceration and edema in dependent limbs; avoid in venous disease and clean granulating wounds |
Do not debride a stable, dry, adherent eschar without erythema, drainage or fluctuance on the heel or on an ischemic limb; it acts as a natural cover. If the eschar becomes boggy, draining or surrounded by redness, it needs medical evaluation and debridement. Ischemic wounds should not be sharply debrided until perfusion has been assessed and, ideally, restored.
Reasoning: A stable dry eschar on a poorly perfused limb should be left intact, kept dry and protected, and the patient referred to the vascular team. Sharp debridement would open a wound that cannot heal and invite infection, and autolytic debridement under an occlusive dressing would soften the eschar and risk wet gangrene. The best answer is protection, offloading and vascular referral. Safety point: watch daily for new redness, fluctuance or drainage, which would change the plan to urgent medical care.
Moisture balance and dressing selection
A moist (not wet) wound environment speeds epithelial migration, supports autolysis and reduces pain. Dressings are chosen to add moisture to a dry wound, absorb from a wet one, and protect the periwound skin from maceration. Fill dead space loosely (packing tunnels and undermining with gauze, alginate or other filler), and keep the wound warm.
| Dressing | Absorbency | Indications | Avoid or caution |
|---|---|---|---|
| Transparent film | None | Superficial wounds, stage 1 and shallow stage 2, protection, securing other dressings; allows inspection | Draining or infected wounds; fragile skin (can tear on removal) |
| Hydrocolloid | Low to moderate | Clean partial thickness wounds with light drainage; promotes autolysis; can stay several days | Infected wounds, heavy drainage, fragile periwound skin; residue and odor are normal |
| Hydrogel | Very low (donates moisture) | Dry wounds, painful wounds, radiation burns, softening dry slough | Heavily draining wounds (macerates periwound skin) |
| Foam | Moderate to high | Moderate to heavy drainage, cushioning over prominences, under compression | Dry wounds |
| Calcium alginate | High | Heavy drainage, cavities and tunnels; mildly hemostatic; forms a gel | Dry wounds or dry eschar (dries and sticks); needs a secondary dressing |
| Hydrofiber (gelling fiber) | High | Heavy drainage; gels vertically so it protects the periwound | Dry wounds |
| Gauze | Variable | Packing, cover dressing, inexpensive | Dries out and adheres; frequent changes cool the wound |
| Antimicrobials (silver, cadexomer iodine, honey, PHMB) | Varies with base | Heavy bioburden or local infection, used for a limited trial (often about 2 weeks) | Iodine with thyroid disease, large wounds, pregnancy; silver can stain; reassess often |
Infection
All chronic wounds carry bacteria. The levels are contamination (bacteria present, not multiplying), colonization (multiplying without harm), local or covert infection (bioburden impairs healing: stalled healing, friable bright red granulation, new odor, increased exudate, new pain, pocketing), and spreading infection (cellulitis, warmth, induration, lymphangitis, fever). Biofilm, a protected community of bacteria in a slimy matrix, is present in most chronic wounds and is removed mainly by repeated debridement and cleansing. Deep or spreading infection requires systemic antibiotics, so report it promptly. When cultures are ordered, the Levine technique swabs clean, viable tissue after cleansing (rotate the swab over a 1 cm area with enough pressure to express fluid); a tissue biopsy is the most accurate method.
Offloading and compression
For plantar neuropathic ulcers, the total contact cast is the reference standard: a well molded, minimally padded cast that spreads load across the whole plantar surface and enforces adherence. It is changed often at first (within days, then weekly). Contraindications include active infection or osteomyelitis, significant arterial insufficiency, a wound deeper than its width, excessive edema that will fluctuate, and inability to walk safely or follow precautions. Alternatives are a removable cast walker (made irremovable when possible), healing sandals, wedge shoes and felt padding. After healing, protective footwear with custom insoles prevents recurrence.
For venous wounds, compression is the core treatment once arterial disease has been excluded. Full compression (about 40 mmHg at the ankle with multilayer or short stretch systems) is commonly used when the ABI is 0.8 or higher; reduced compression is considered between about 0.5 and 0.8 with medical oversight, and sustained compression is avoided below about 0.5. Combine with elevation above heart level for periods during the day, ankle pumping and walking to activate the calf muscle pump, and lifelong stockings after healing.
Adjunct modalities
| Adjunct | Common parameters or use | Contraindications and cautions |
|---|---|---|
| Electrical stimulation (high voltage pulsed current) | Electrode on the wound over saline moistened gauze; commonly about 100 to 150 pulses per second, sensory level, 45 to 60 minutes, 5 to 7 days a week; negative pole often taught for infected or inflammatory phase wounds and positive pole to promote epithelialization | Malignancy in the area, untreated osteomyelitis, over a pacemaker or the heart, topical metal ions (silver, iodine) left in the wound, over the carotid sinus |
| Negative pressure wound therapy | Foam or gauze under a seal with suction, typically about 125 mmHg continuous (lower or intermittent options exist); removes exudate, reduces edema, draws edges together, stimulates granulation | Malignancy in the wound, untreated osteomyelitis, unexplored or nonenteric fistula, necrotic tissue with eschar, exposed vessels, nerves or organs; caution with anticoagulation and active bleeding |
| Noncontact low frequency ultrasound | Kilohertz range mist delivered through saline, used for debridement and stimulation | Over malignancy, pacemaker, active bleeding |
| Hyperbaric oxygen | Breathing 100% oxygen at increased atmospheric pressure in a chamber; used for selected diabetic foot ulcers (Wagner 3 or higher), radiation injury, refractory osteomyelitis | Untreated pneumothorax; caution with seizures, COPD with CO2 retention, claustrophobia |
Reasoning: Heavy exudate plus maceration means the current hydrogel is adding moisture to an already wet wound. Switch to a highly absorptive dressing (alginate or hydrofiber with a foam cover), protect the periwound with a skin barrier, and apply multilayer compression, which is safe with an ABI of 0.95. Elevation and calf pumping complete the plan. Choosing a transparent film or hydrocolloid would trap exudate; choosing compression without checking the ABI would be unsafe in another patient. Safety point: compression treats the cause of a venous wound, and the dressing only manages its drainage.
Treat the cause first, then prepare the bed: remove nonviable tissue, control bioburden, balance moisture and advance the edge. Sharp, enzymatic, autolytic and larval debridement are selective; wet to dry, whirlpool and pulsed lavage are not. Leave stable dry eschar on heels and ischemic limbs. Choose dressings by drainage (hydrogel to film and hydrocolloid to foam to alginate and hydrofiber) and add antimicrobials for infection. Offload neuropathic feet with a total contact cast, compress venous legs after checking ABI, and know the contraindications for electrical stimulation and negative pressure therapy.
Section 4Burns
Burn depth
Burns are caused by heat (thermal), chemicals, electricity and radiation. Depth depends on temperature and duration of contact and on skin thickness: thin skin of children, older adults and the inner arm burns deeper. The central area of a burn, the zone of coagulation, is irreversibly destroyed; around it the zone of stasis has reduced blood flow and can survive or die depending on resuscitation, infection and edema; the outer zone of hyperemia recovers. Depth is often hard to judge on day one and declares itself over several days.
| Depth | Layers involved | Appearance | Sensation | Healing |
|---|---|---|---|---|
| Superficial (first degree) | Epidermis only | Red, dry, no blisters, blanches (sunburn) | Painful | 3 to 7 days, no scar |
| Superficial partial thickness | Epidermis and papillary dermis | Blisters, moist, bright red, blanches with brisk refill | Very painful, sensitive to air and touch | About 1 to 3 weeks, minimal scar, possible pigment change |
| Deep partial thickness | Epidermis and into reticular dermis | Mottled red and waxy white, drier, blisters often broken, slow or absent blanching | Decreased light touch and pain; pressure sense often preserved | 3 to 5 weeks or longer; hypertrophic scar likely; often grafted |
| Full thickness (third degree) | Entire epidermis and dermis, into subcutaneous tissue | White, tan, brown or black, leathery, dry, no blanching, thrombosed vessels visible | Insensate (nerve endings destroyed), though edges hurt | Will not heal except from the edges; needs grafting |
| Subdermal (fourth degree) | Through fat into muscle, tendon or bone | Charred | Insensate | Grafts, flaps, often amputation; electrical injuries |
Burn size: the rule of nines
Burn size is expressed as percent of total body surface area (TBSA), counting partial and full thickness burns only (not superficial). The adult rule of nines assigns 9% to the head and neck, 9% to each arm, 18% to the front of the trunk, 18% to the back of the trunk, 18% to each leg and 1% to the perineum. Children have proportionally larger heads and smaller legs (in an infant, the head is about 18% and each leg about 14%), so the Lund and Browder chart, which adjusts for age, is more accurate. For scattered or small burns, the patient's palm including the fingers is roughly 1% TBSA.
Acute care
Major burns cause massive capillary leak and fluid shifts in the first 24 to 48 hours. Fluid resuscitation is commonly estimated with the Parkland formula: 4 mL of lactated Ringer solution times body weight in kg times %TBSA over 24 hours, half in the first 8 hours from the time of injury; urine output guides adjustment. Other priorities:
- Inhalation injury: suspect with facial burns, singed nasal hair, soot in the mouth or sputum, hoarseness, stridor, or a fire in an enclosed space. Carbon monoxide poisoning makes SpO2 falsely normal.
- Circumferential full thickness burns form an inelastic eschar that, as edema builds, can cut off circulation in a limb or restrict chest expansion. An escharotomy (incision through the eschar) relieves it; monitor distal pulses, capillary refill and sensation.
- Electrical injuries look small on the skin (entry and exit wounds) but damage deep tissue along the current path: risk of arrhythmia, compartment syndrome, rhabdomyolysis with kidney injury, and delayed neurologic deficits and cataracts.
- Hypermetabolism raises energy needs dramatically and causes muscle wasting; infection is the leading cause of death after the first days.
Grafts and skin substitutes
Excision of deep burns and early grafting shortens healing and reduces scarring. Grafts are classified by source and thickness.
- Autograft: the patient's own skin, the only permanent graft. A split thickness skin graft takes epidermis and part of the dermis; the donor site heals like a superficial partial thickness wound in about 1 to 2 weeks and is often more painful than the graft site. A full thickness graft takes the entire dermis, contracts less and looks better, so it is used on the face and hands, but the donor site must be closed.
- Sheet graft (unmeshed) gives the best appearance; mesh graft is cut in a pattern and expanded to cover more area and let fluid escape, but heals with a mesh pattern and more scarring.
- Allograft (human cadaver skin), xenograft (usually pig skin) and synthetic or biosynthetic substitutes provide temporary cover; cultured epidermal autografts and dermal substitutes are used in very large burns.
After grafting, the area is immobilized, typically for about 3 to 5 days (per surgeon protocol), to let the graft adhere and vascularize; shear and range of motion of that area are avoided, while uninvolved joints keep moving. Ambulation after a leg graft waits for surgeon clearance and requires compressive wrapping to prevent venous pooling under the graft. Once cleared, range of motion resumes with careful observation of the graft.
Positioning and contracture prevention
Burned tissue contracts as it heals, and the position of comfort, usually flexion and adduction, is the position of contracture. Splints and positioning hold the opposite position from the start, combined with frequent active range of motion.
| Area burned | Contracture tendency | Antideformity position |
|---|---|---|
| Anterior neck | Flexion | Neck in slight extension; no pillow under the head (a towel roll under the shoulders), neck conformer |
| Axilla and shoulder | Adduction, internal rotation | Shoulder abduction about 90 degrees (up to about 110), slight horizontal adduction to protect the brachial plexus, neutral rotation |
| Anterior elbow | Flexion, pronation | Elbow extension, forearm supination |
| Wrist and dorsal hand | Wrist flexion, MCP hyperextension, IP flexion, thumb adduction (claw) | Wrist extension about 15 to 30 degrees, MCP flexion about 60 to 90, IP extension, thumb abducted (intrinsic plus position) |
| Palm | Finger flexion, cupping | Fingers and thumb extended and abducted (palmar extension splint) |
| Hip and groin | Flexion, adduction | Hip extension, abduction about 10 to 20 degrees, neutral rotation; prone lying |
| Knee | Flexion | Knee extension |
| Ankle | Plantarflexion | Ankle neutral (90 degrees), splint or boot |
Scar management
A hypertrophic scar is raised, red and firm but stays within the boundary of the original wound, and often improves over 1 to 2 years. A keloid grows beyond the boundary of the wound, rarely regresses, and is more common in darker skin. Hypertrophic scarring is most likely when a burn takes longer than about 2 to 3 weeks to heal. Management:
- Pressure garments: custom fitted, providing about 25 mmHg, worn about 23 hours a day until the scar matures (often 12 to 18 months or more), removed only for bathing. Interim wraps or tubular sleeves start once wounds are mostly closed.
- Silicone gel sheets to hydrate and flatten scar, scar massage once the skin tolerates it, stretching and serial splinting or casting for developing contractures.
- Skin care: moisturize (grafted and healed skin lacks oil and sweat glands), protect from sun for at least a year to prevent hyperpigmentation, and expect itching (pruritus) and heat intolerance.
- A scar is mature when it is pale, flat, soft and pliable. Scar is measured with tools such as the Vancouver Scar Scale (pigmentation, vascularity, pliability, height).
Reasoning: TBSA: right arm 9% plus anterior trunk 18% plus anterior right leg 9% equals 36%. The arm and trunk are deep partial thickness; the leg is superficial partial thickness. Because axillary and anterior trunk burns tend toward adduction and flexion, position the right shoulder in about 90 degrees of abduction with slight horizontal adduction, and remove the pillow from under his head if the anterior neck or upper chest is involved. A tempting error is to count superficial burns or to estimate the whole leg as 9%: each full leg is 18%. Safety point: watch the circumferential arm burn for loss of distal pulses, capillary refill or sensation, which calls for urgent escharotomy evaluation.
Burn depth is read from blisters, color, blanching and sensation: superficial partial thickness burns blister and hurt and heal in under 3 weeks; deep partial thickness burns are mottled and slow; full thickness burns are leathery, insensate and need grafting. Size burns with the rule of nines in adults and an age adjusted chart in children. Protect grafts for about 3 to 5 days, splint and position against the contracture pattern from day one, and manage hypertrophic scar with pressure garments worn about 23 hours a day for a year or more, silicone and stretching.
Section 5Skin conditions and integumentary screening
Why physical therapists screen the skin
Therapists see skin that physicians may not: the back during a lumbar exam, the feet during gait training, the whole body during aquatic or wound care. Every examination includes inspection of the areas you treat, and every thermal agent, electrode or compression wrap begins with a skin check. Note color, temperature, texture, moisture, turgor, edema, lesions, scars, hair and nails, and ask how long any lesion has been present and whether it has changed.
Skin cancer warning signs
The three common skin cancers differ in behavior.
| Cancer | Typical appearance and site | Behavior |
|---|---|---|
| Basal cell carcinoma | Pearly or waxy papule with rolled edges and fine surface vessels (telangiectasia), may ulcerate centrally; face, ears, neck | Most common; grows slowly and invades locally; rarely metastasizes |
| Squamous cell carcinoma | Firm, scaly, crusted or ulcerated red lesion on sun exposed skin, lips, old scars; actinic keratosis (rough scaly patch) is the precursor | Second most common; can metastasize, especially on lips and ears and in immunosuppressed patients |
| Melanoma | New or changing pigmented lesion meeting ABCDE criteria; anywhere, including soles, nails and the back | Least common of the three but causes most skin cancer deaths; prognosis depends on depth |
The ABCDE rule flags pigmented lesions for referral: Asymmetry, Border irregularity (notched, ragged or blurred), Color variation (shades of brown, black, red, white or blue), Diameter greater than about 6 mm (the size of a pencil eraser), and Evolving (changing in size, shape, color or elevation, or new itching or bleeding). Evolution is the most important single sign. The "ugly duckling" sign, a mole that looks different from the patient's other moles, adds sensitivity. Risk factors include fair skin, blistering sunburns in childhood, many or atypical moles, family history, tanning bed use and immunosuppression.
Skin infections and infestations
| Condition | Key features | PT action |
|---|---|---|
| Cellulitis | Spreading, poorly demarcated redness, warmth, swelling and tenderness, often on a leg; fever, red streaks (lymphangitis) | Refer for antibiotics; mark the border; hold compression and massage on that limb |
| Necrotizing fasciitis | Pain out of proportion to findings, rapid spread, tense swelling, dusky or purple skin, bullae, crepitus, systemic toxicity | Emergency surgical referral |
| Impetigo | Honey colored crusts, often around nose and mouth in children; staphylococcal or streptococcal | Contagious; refer; contact precautions |
| Abscess, MRSA | Painful fluctuant red nodule, may drain pus; often mistaken for a spider bite | Refer for drainage; contact precautions; clean equipment |
| Herpes zoster (shingles) | Burning or tingling pain in one dermatome followed by clustered vesicles that do not cross the midline | Refer early for antivirals; lesions are contagious to people without immunity until crusted; postherpetic neuralgia may follow |
| Fungal (tinea, candidiasis) | Tinea: ring shaped scaly plaques, athlete's foot between toes; candida: red moist rash with satellite lesions in skin folds | Keep skin dry; refer for antifungal; tinea pedis cracks are an entry point for cellulitis in diabetes |
| Scabies | Intense itching worse at night, burrows in finger webs, wrists, waistline | Contact precautions; refer; treat close contacts |
Inflammatory and systemic skin signs
- Psoriasis: well demarcated red plaques with silvery scale on extensor surfaces (elbows, knees), scalp and lumbosacral area; nail pitting; about a quarter to a third develop psoriatic arthritis (DIP involvement, dactylitis, sacroiliitis).
- Atopic dermatitis (eczema): itchy, dry, lichenified patches in flexural creases; associated with asthma and allergies.
- Systemic lupus erythematosus: butterfly (malar) rash sparing the nasolabial folds, photosensitivity. Dermatomyositis: heliotrope (violet) eyelid rash and Gottron papules over the knuckles with proximal weakness. Scleroderma: tight, thickened skin, Raynaud phenomenon, finger ulcers.
- Systemic clues: cyanosis (central in lips and tongue suggests hypoxemia), jaundice (liver disease), pallor (anemia), petechiae and easy bruising (low platelets, anticoagulation, steroid use), clubbing (chronic hypoxia, lung cancer, cystic fibrosis), spider angiomas and palmar erythema (liver disease), café au lait spots (neurofibromatosis), and a dermatomal rash.
- Drug reactions range from mild rashes to emergencies: a widespread rash with blistering, mucosal sores and fever suggests Stevens Johnson syndrome and needs emergency care.
Edema assessment
Edema is graded by pitting depth and rebound time. Scales differ between sources; a commonly used version:
| Grade | Pit depth | Rebound |
|---|---|---|
| 1+ (trace) | About 2 mm | Disappears almost immediately |
| 2+ (mild) | About 4 mm | Within about 15 seconds |
| 3+ (moderate) | About 6 mm | Up to about 1 minute |
| 4+ (severe) | About 8 mm | 2 to 5 minutes |
Also note the distribution. Bilateral dependent pitting edema points to systemic causes (heart failure, kidney or liver disease, low albumin, medications such as calcium channel blockers). Unilateral edema points to a local cause (DVT, cellulitis, lymphedema, venous insufficiency, injury, or a mass obstructing outflow). Sudden unilateral swelling with warmth and calf pain needs same day DVT evaluation. Girth and figure of eight measurements (for the ankle and hand) or volumetry track change.
Prevention education
- Diabetic foot care: inspect the feet every day (use a mirror or a helper), wash and dry carefully between the toes, moisturize but not between the toes, never walk barefoot, check shoes for objects before wearing, choose well fitting protective footwear, have nails and callus treated by a professional, and report any break, color change or swelling at once.
- Pressure injury prevention for wheelchair users and those with sensory loss: daily skin checks, scheduled pressure relief, cushion maintenance, moisture management and nutrition.
- Sun protection: broad spectrum sunscreen of SPF 30 or higher, reapplied every 2 hours outdoors and after swimming, protective clothing and hats, shade during peak sun hours, no tanning beds, and regular skin self checks. Healed burns and grafts burn easily.
- Modality safety: before heat, cold or electrical stimulation, check sensation and skin integrity, and recheck the skin during and after treatment. Patients with impaired sensation, poor circulation, or new or thin scar are at higher risk of burns.
- Skin tear prevention in older adults: lift rather than drag, pad bed rails and wheelchair parts, use long sleeves, avoid adhesive tape on fragile skin, and moisturize.
Reasoning: The lesion meets several ABCDE criteria (color variation, irregular border, diameter greater than 6 mm, and evolution), so it is suspicious for melanoma. The best action is to document it and recommend prompt evaluation by his physician or a dermatologist, explaining why without diagnosing. Ignoring it because it is outside the plan of care, or telling him it is cancer, are both wrong. Safety point: screening for conditions outside the referral diagnosis is part of physical therapist practice, and evolution of a lesion is the most important warning sign.
Inspect the skin in every patient you treat. Use ABCDE and the ugly duckling sign to refer suspicious moles, and remember basal cell is most common while melanoma is most deadly. Spreading redness and fever mean cellulitis (refer, hold compression); pain out of proportion means possible necrotizing fasciitis (emergency). Grade edema by pitting and rebound, and let its distribution guide you toward systemic or local causes. Teach daily foot inspection in diabetes, pressure relief in sensory loss and sun protection for everyone, especially after burns.
The chapter in one breath
- The avascular epidermis rests on the vascular dermis; surviving hair follicles and sweat glands let partial thickness wounds regenerate.
- Healing moves through inflammation, proliferation (granulation, contraction, epithelialization) and remodeling; scar regains only about 80% of strength.
- Document size head to toe, undermining and tunneling by the clock (12 toward the head), tissue type, exudate, edges and periwound.
- Pressure injury stages 1 to 4 follow the deepest tissue visible, plus unstageable and deep tissue injury, and are never reverse staged.
- The Braden scale runs 6 to 23, and 18 or less means risk: turn, float heels, use 30 degree positions and teach seated pressure relief.
- Arterial wounds are distal, punched out and painful; venous wounds are medial, shallow and wet; neuropathic wounds are plantar, callused and painless.
- Debridement is selective (sharp, enzymatic, autolytic, larval) or nonselective (wet to dry, whirlpool, lavage); leave stable dry eschar on heels and ischemic limbs.
- Match dressings to moisture: hydrogel for dry, film and hydrocolloid for minimal, foam for moderate, alginate and hydrofiber for heavy; no occlusion over infection.
- Offload neuropathic ulcers with a total contact cast; compress venous wounds after an ABI check.
- Burn depth: blisters and pain mean superficial partial thickness; mottled and slow means deep partial; leathery and insensate means full thickness. Size with the rule of nines.
- Position against contracture, protect grafts for about 3 to 5 days, and use pressure garments about 23 hours a day until scar matures.
- Refer ABCDE lesions, cellulitis and shingles; treat suspected necrotizing fasciitis as an emergency.
Words worth knowing
| Term | What it means |
|---|---|
| Epidermis | The outer, avascular layer of skin made of keratinocytes, renewed from the stratum basale. |
| Dermis | The vascular connective tissue layer beneath the epidermis containing collagen, nerves, hair follicles and glands. |
| Granulation tissue | Moist, red, bumpy new tissue of capillaries and collagen that fills a wound during proliferation. |
| Epithelialization | Migration of keratinocytes across the wound surface to close it. |
| Wound contraction | Inward pulling of wound edges by myofibroblasts, which reduces the area to be closed. |
| Secondary intention | Healing of an open wound by granulation, contraction and epithelialization. |
| Undermining | Tissue destruction under intact skin along the wound edge, spanning part of the perimeter. |
| Tunneling | A narrow channel extending from the wound into deeper tissue in one direction. |
| Slough | Soft, moist, yellow, tan or gray nonviable tissue in the wound bed. |
| Eschar | Thick, dry, black or brown leathery necrotic tissue. |
| Epibole | Rolled, curled wound edges that stop epithelial migration. |
| Maceration | Softened, white, waterlogged skin from prolonged moisture. |
| Deep tissue pressure injury | Persistent nonblanchable maroon or purple discoloration from pressure damage at the bone muscle interface. |
| Unstageable pressure injury | A full thickness pressure injury whose base is hidden by slough or eschar. |
| Braden scale | A six item pressure injury risk tool scored 6 to 23, with lower scores meaning higher risk. |
| Shear | Force from the skeleton sliding while the skin is held in place, which kinks deep vessels. |
| Loss of protective sensation | Inability to feel the 10 gram monofilament, which puts the foot at high risk of ulceration. |
| Total contact cast | A closely molded walking cast that redistributes plantar pressure to heal neuropathic ulcers. |
| Selective debridement | Removal of only nonviable tissue, by sharp, enzymatic, autolytic or larval methods. |
| Autolytic debridement | Breakdown of necrotic tissue by the body's own enzymes under a moisture retentive dressing. |
| Biofilm | A protected community of bacteria within a matrix on the wound surface that resists antibiotics. |
| Alginate | A highly absorbent seaweed derived dressing that forms a gel and fills cavities. |
| Negative pressure wound therapy | Suction applied through a sealed foam dressing to remove exudate and promote granulation. |
| Zone of stasis | The area around a burn's dead center with reduced blood flow that can survive or die. |
| Escharotomy | Surgical incision through a circumferential burn eschar to restore circulation or breathing. |
| Split thickness skin graft | An autograft of epidermis and part of the dermis taken from a donor site that heals on its own. |
| Mesh graft | A graft cut in a pattern and expanded to cover a larger area and allow drainage. |
| Hypertrophic scar | A raised, red, firm scar that stays within the original wound boundary. |
| Keloid | A scar that grows beyond the boundary of the original wound and rarely regresses. |
| ABCDE rule | Asymmetry, border, color, diameter and evolution: warning signs of melanoma. |