11.6 Burns, Endocrine/Metabolic & Medical Complications Rehabilitation
Key Takeaways
- Burn depth determines healing and rehab need: superficial partial-thickness (epidermis/upper dermis) heals within ~2 weeks with minimal scarring; deep partial-thickness heals in >3 weeks with hypertrophic scarring risk; full-thickness requires excision and grafting.
- Total body surface area (TBSA) is estimated in adults by the Rule of Nines (head/each arm 9%, anterior trunk 18%, posterior trunk 18%, each leg 18%, perineum 1%); Lund-Browder charts refine pediatric estimates.
- Burn rehabilitation targets contracture prevention (positioning, splinting in anti-deformity positions, early and sustained ROM), hypertrophic scar management (pressure garments ~23-24 hr/day for many months), and functional reintegration; edema, pruritus, and heterotopic ossification are common complications.
- Endocrine and metabolic rehab considerations include diabetic foot ulceration and glycemic control impact on wound healing, thyroid dysfunction and myopathy, and post-bariatric/immobility-related metabolic bone disease; malnutrition and edema impede wound healing.
Burns, Endocrine/Metabolic & Medical Complications Rehabilitation
Burns (Domain E condition) and endocrine/metabolic disorders plus delirium, edema, malnutrition, sleep, and wound care (Domain E rehab management) are consolidated here.
Burn Depth & Classification
| Depth | Layers | Healing | Rehab Implication |
|---|---|---|---|
| Superficial (1st degree) | Epidermis | ~3-6 days, no scar | Symptomatic care |
| Superficial partial-thickness (2nd) | Epidermis + upper dermis, blanching, moist, painful | ~1-2 weeks, minimal scar | Wound care, ROM |
| Deep partial-thickness (2nd) | Into reticular dermis, less blanching, may be less painful | >3 weeks, hypertrophic scar risk | Grafting often considered; aggressive scar/contracture mgmt |
| Full-thickness (3rd) | Full dermis, dry, leathery, insensate | No spontaneous healing; excision/grafting | Surgical + intensive rehab |
| 4th degree | Into fascia/muscle/bone | Surgical | Limb salvage vs amputation |
TBSA Estimation (Adult Rule of Nines)
Head & neck 9% Anterior trunk 18%
Each upper arm 9% Posterior trunk 18%
Each lower leg 18% Perineum 1%
(Rule of Nines; Lund-Browder chart adjusts pediatric proportions.)
TBSA guides fluid resuscitation (Parkland formula: 4 mL x kg x %TBSA in first 24 hr, half in first 8 hr) and prognosis.
Burn Rehabilitation Priorities
- Anti-deformity positioning: splint and position joints to oppose the tendency toward contracture (e.g., axillary abducted ~90°, elbow extended, wrist neutral-to-slightly extended, MCPs flexed ~70° with IPs extended, knees extended, ankles dorsiflexed). Contracture prevention begins during acute care.
- Range of motion: early, sustained, and frequent; coordinate with pain control and graft integration (immobilize freshly grafted areas per burn team).
- Hypertrophic scar management: pressure garments worn ~23-24 hours daily for many months to a year; silicone gel sheeting; massage and moisturization.
- Edema: elevation, compression once grafts stable, active exercise.
- Pruritus: moisturizers, antihistamines, cooling agents.
- Heterotopic ossification: elbow most common; prophylaxis (early ROM) and management.
- Functional reintegration: scar maturation (up to 1-2 years), psychological support, return to work/school, prosthetics if amputation.
Endocrine & Metabolic Considerations in Rehab
| Condition | Rehab-Relevant Issue |
|---|---|
| Diabetes mellitus | Diabetic foot ulcers (offloading, total-contact casting), neuropathy, glycemic control essential for wound healing |
| Thyroid | Hypothyroid myopathy (proximal weakness, slowed reflexes); hyperthyroid myopathy |
| Glucocorticoids | Steroid myopathy, osteoporosis, hyperglycemia impairing healing |
| Post-bariatric / malabsorption | Vitamin D/calcium deficiency, osteoporosis, neuropathy (B1/B12) |
| Immobility | Hypercalcemia (esp. young SCI/children), disuse osteopenia |
| Chronic kidney disease | Renal osteodystrophy, sarcopenia, anemia limiting exercise |
Medical Complications Across Rehab (Delirium, Edema, Malnutrition, Sleep)
- Delirium: common in inpatient rehab (older adults, postop, infection, medication); screen (CAM), address precipitants, orient, mobilize, normalize sleep-wake cycle; avoid deliriogenic sedatives.
- Edema: dependent edema, venous insufficiency, lymphedema, cardiac/renal causes; compression, elevation, exercise, and treatment of underlying cause.
- Malnutrition: impairs wound healing and increases pressure injury risk; protein intake ~1.2-1.5 g/kg/day for wound/healing, screen (MNA/SNAQ), dietitian referral.
- Sleep: pain, depression, nocturia, medications, and respiratory disorders impair recovery; sleep hygiene and treating underlying causes.
- Wound care: covered in the pressure-injury section; principles—debridement, moisture balance, offloading, infection control.
Burn Severity, Inhalation Injury & Systemic Response
Major burn severity reflects TBSA, depth, inhalation injury, comorbidity, age, and location (face, hands, feet, perineum, joints). Inhalation injury (soot, hoarseness, singed nares, carbonaceous sputum, enclosed-space injury) substantially increases mortality and requires airway vigilance; early intubation for impending airway compromise. The hypermetabolic response persists for months, with hyperthermia, tachycardia, catabolism, and insulin resistance; beta-adrenergic blockade (propranolol) and anabolic agents (oxandrolone) attenuate catabolism in select centers.
Scar Maturation, Pruritus & Psychological Recovery
Hypertrophic scars mature over 1-2 years; pressure garment therapy (~23-24 hr/day for 9-12 months or until scar maturity), silicone sheeting, massage, moisturization, and sun protection optimize appearance and pliability. Pruritus is nearly universal and managed with moisturizers, antihistamines, counter-irritants, and gabapentinoids for neuropathic itch. Psychological recovery addresses pain, body image, sleep disturbance, PTSD, and reintegration into work/school; psychologic support is integral from admission through outpatient reintegration.
Endocrine Myopathies & Rehab Recognition
Endocrine disorders produce characteristic patterns the physiatrist should recognize: hypothyroid myopathy (proximal weakness, delayed reflexes, myoedema, elevated CK), hyperthyroid myopathy (proximal weakness with normal CK), steroid myopathy (chronic glucocorticoid proximal weakness, often type II fiber atrophy, improve with taper and exercise), and parathyroid/myopathy patterns. Recognition prompts endocrine evaluation and management of the underlying disorder, with rehabilitation of residual weakness.
Delirium Prevention & Sleep Optimization in Inpatient Rehab
| Delirium Risk Factor | Intervention |
|---|---|
| Infection, hypoxia, metabolic derangement | Identify and treat precipitants |
| Polypharmacy (anticholinergic, benzodiazepine) | Deprescribe deliriogenic agents |
| Sensory impairment, disorientation | Glasses/hearing aids, orient, clocks/calendars |
| Immobility, restraint use | Mobilize early; minimize restraints |
| Sleep disruption | Normalize sleep-wake cycle, reduce nocturnal disruptions |
Sleep optimization in rehab addresses pain, nocturia, sleep apnea, anxiety, medication timing, and environmental noise. Recognizing and treating delirium and sleep disorders accelerates participation and functional gains, making them core—not peripheral—rehabilitation medical-management tasks.
A burn patient is splinted after grafting. Which positioning best prevents contracture at the axilla and elbow?
A patient with full-thickness burns covering 36% TBSA requires resuscitation. Using the Parkland formula, which is the correct 24-hour fluid volume for a 70 kg adult?
Which factor most directly impairs wound healing and increases pressure-injury risk in a rehab inpatient?