Wounds/Burns

Question 1

Wound Closure
1. Primary
2. Secondary
3. Delayed primary

Answer 1

1. Primary—Wound is closed with sutures.
2. Secondary—Wound is left open and allowed to close on its own.
3. Delayed primary—Wound is cleaned, debrided, and observed 4 to 5 days before suturing it closed.

Question 2

Wound Healing Phases

Answer 2

1. inflammatory
2. proliferative
3. remodeling

Question 3

Inflammatory phase

Wound healing

Answer 3

1. process includes clotting and vasoconstriction, white blood cell migration, and release of histamines and prostaglandins that cause vasodilation and increased tissue permeability.
2. The acute phase lasts 24–48 hours to 7 days, and the **subacute phase lasts 7 to 14 days. Local signs include redness, swelling, heat, and pain;** systemic signs are fever and leukocytosis.

Question 4

Proliferative phase

Wound healing

Answer 4

1. (also called the fibroplastic, granulation, or epithelialization process), lactic acid and ascorbic acid stimulate fibroblasts to synthesize collagen, and cross linkage of collagen increases the tensile strength of repaired skin to 80%.
2. Epithelialization resurfaces the wound, tissue granulation forms new collagen and blood vessels, and myofibroblasts connect to the wound margins.
3. Wound contraction lasts 5 days to 2–3 weeks. Linear wounds heal quickly, rectangular wounds moderately quickly, and circular wounds the most slowly.

Question 5

Remodeling Phase

Wound healing, splint, modalities

Answer 5

1. scar tissue first consists of randomly arranged collagen fibers, and as the scar matures, the collagen is broken down and remodeled. The scar is then more elastic, smoother, and stronger.
2. lasts 2 weeks to 1–2 years. If collagen synthesis exceeds collagen lysis, hypertrophic and keloid scars can form.
3. Tension theory posits that wearing pressure garments helps collagen fibers realign in a linear and lateral orientation.
4. Dynamic splinting, serial casting, continuous passive motion, positional stretching, NMES, and silastic gel pads can help decrease hypertrophic scarring.

Question 6

Name the 4 classification of burns.

Answer 6

1. Superficial (1st-degree) burn
2. Superficial partial-thickness (2nd-degree) burn
3. Deep partial-thickness (deep 2nd-degree) burn
4. Full-thickness (3rd degree) burn
5. Subdermal burn

Question 7

Superficial burn

Location, symptoms, healing time

Answer 7

1. Involves the superficial epidermis ONLY.
2. Min-Mod pain; no blistering, min. erythema.
3. Healing time: 3–7 days.

Question 8

Superficial partial-thickness burn

Location, symptoms, healing time

Answer 8

1. Involves the epidermis and upper dermis layers.
2. Pain is significant; wet blistering and erythema are present.
3. Healing time: 1–3 weeks.

Question 9

Deep partial-thickness (deep second-degree) burn

Location, symptoms, healing time

Answer 9

1. Involves the epidermis and the deep dermis layers, hair follicles, and sweat glands.
2. Pain is severe, even to light touch.
3. Erythema is present, with or without blisters.
4. Burn has a high risk of turning into a full-thickness burn because of infection; grafting may be considered to prevent wound infection.
5. Client may have impairment of sensation.
6. Potential for hypertrophic scar is high.
7. Healing time: varies from 3–5 weeks.

Question 10

Full-thickness (third-degree) burn

Location, symptoms, treatment, healing time

Answer 10

1. Involves the epidermis and dermis, hair follicles, sweat glands, and nerve endings.
2. Burn is pain free, no sensation to light touch.
3. Burn is pale and nonblanching.
4. Requires skin graft.
5. Potential for hypertrophic scar is extremely high.

Question 11

Subdermal burn

Location, symptoms, healing time

Answer 11

1. Full-thickness burn with damage to underlying tissue such as fat, muscles, and bone.
2. Charring is present; may have exposed fat, tendons, or muscles.
3. If the burn is electrical, destruction of nerve along the pathway is present.
4. Peripheral nerve damage is significant.
5. Requires surgical intervention for wound closure or amputation.
6. Potential for hypertrophic scar is extremely high.

Question 12

Emergent phase

Burn

Answer 12

0-72 hrs after injury

Medical management:
-sustaining life, controlling infection, and managining pain.

OT Eval: observation of body parts affected by burn; PLOF

OT intervention: splinting in antideformity positions
1. intrinsic plus for hands
2. opposite client’s posture
3. generally in extension for neck, elbows, and knees
4. shoulder in abduction and hip in extension
5. anti-frog leg & anti-foot drop for LE

Question 13

Xenografts

Answer 13

bovine (cattle) skin, processed pig skin

Biologic dressing for wounds

Question 14

Allograft

Answer 14

human cadaver skin

Biologic dressing for wounds

Question 15

Acute phase

Burn

Answer 15

72 hrs after injury/until wound is closed (days/months)
OT FOCUS: preserve ROM, functional strength, build cardiop. endurance, decrease edema

Medical Management: infection control (non-surg/surg), pain management, nutrition/hydration (high protein diet for wound healing), and cardiopulmonary stability.

OT Eval: ADls, psychosocial, communication, cog., ROM, strength, and pain

OT Intervention:
1. splinting/positioning (anti-deformity position)
2. edema (elevation, AROM ex, if allowed, elastic bandage/bulk wound dressing)
3. ADL (self-care) with AE (compression wrapping before walking/standing/prolonged sitting)
4. ROM program as tolerated. NO PASSIVE/ACTIVE ROM with exposed tendons/recent grafts (wait 5-7 days)
5. pain management: visual imagery, relaxation, schedule around meds
6. education (burn stages, importance of ADL/Ex, pain management tech)

Question 16

Splint for Wrist (DORSAL) burn

Answer 16

1. neutral-30 d ext
2. wrist extension splint

Question 17

Splint for Wrist (VOLAR) burn

Answer 17

1. wrist cockup splint (5-10d ext)

Question 18

Anticontracture Positioning for Burns

Answer 18

1. Neck: neutral to slight extension
2. Chest and Abd: trunk extension, shoulder retraction
3. Axilla: shoulder abduction (100-120d), slight external rotation
4. Elbow: extension
5. Forearm: neutral to supination
   6. Wrist: neutral- 30d extension (DORSAL); 30-45 D (VOLAR)
6. Hand: MCP (70 Flex), IP (0 ext), thumb abd+ext (claw hand def)
7. Hip: 10-15d abduction, neutral ext
8. Knee: ext; with anterior burn, slight flexion
9. Ankle: neutral-5d dorsiflexion (ankle 90d wtih foot board or splint)

Question 19

Acute phase (POST-OP)

Answer 19

1. immobilization (3-10 days; or 2-3 day for donor site); walking resumes (5-7 days after grafting LE)
2. positioning (donor-elevate and wrap with elastic band)
3. exercise and activity (after immobilization, start with gentle AROM)

Question 20

Rehabilitation phase

Answer 20

Wound is healing; wound closure stable)
Medical: skin grafts/reconstruction surg for movement

OT intervention:
1. skin conditioning (skin lubrication, massage to desentize/scar prevention), sunblock/avoid sun exposure
2. scar management (massage/pressure garments)/edema -elastic bandage, 3m Coban-finger, thigh/knee high hose, isotonic gloves); to be worn 24hr ex bath, ex, massage
3. ex/act/ADLs/AE
4. splinting/edu

Question 21

Hypertrophic scar

description, healing time, treatment

Answer 21

1. thick, firm scar that rises above skin level d/t inc. vascularity; occurs after 2 wks if wound does not close
2. most apparent 6-8 wks after wound closure
3. APPLY COMPRESSION THERAPY until scar maturity (1-2 yrs)
4. use SCAR GEL PADS/INSERTS to provide compression

Question 22

Heterotopic ossification

Answer 22

1. the formation of bones in abnormal areas. It typically occurs in soft tissue around the joint or joint capsule; usually req. surg if function limited
2. occurs in elbow, knee, hip, shoulder; LOSS OF ROM
3. PAIN is localized and severe
4. D/C passive stretch, dynamic splint and begin AROM pain free range

Question 23

What are the goals for pain management in burn rehabilitation?

Answer 23

1. work around pain med schedule
2. educate on ROM exercises and activity in spite of pain to prevent deformity formation
3. skin care and lubrication to avoid stress on skin during exercises/activity

Question 24

What other risk does the burn patient have to be aware of?

A] sun exposure
B] pruritus
C] psychosocial adjustment
D] all of the above

Answer 24

D] all of the above

1. sunburn risk is higher; should use sunscreen and avoid long exposure to sun
2. pruritis (persistent itching) may lead to skin maceration and reopening of the wound; should use compression garment, lub, cold packs, and antihistamine meds.
3. Contracture, disfigurement, and pain may result in depression. anxiety, PTSD, and w/d reactions postburn

Question 25

A client in the acute burn unit sustained full-thickness chemical burns to the bilateral anterior and inner thighs. The client underwent grafting operations 2 weeks ago, and the surgeon has confirmed graft adherence. What would be the OTR®’s BEST choice to initiate compression therapy?

A] Custom-made Jobst garment
B] Spandex bicycle pants
C] Coban self-adherent wrap
D] Thigh-high thromboembolism-deterrent (TED) stocking

Answer 25

Solution: The correct answer is B.

Spandex bicycle pants are sufficient to apply gentle pressure on the anterior and inner-thigh areas without causing excessive shear or pressure on the newly adhered graft.

A: Although a tailor-made Jobst garment is a good choice for compression therapy in the later stage, it is important to initiate compression therapy with lighter pressure for desensitization in the early stage when the wound is still fresh.

C: Coban self-adherent wrap will be difficult to manage in a large area such as the thighs. It is more commonly used in small areas such as the fingers.

D: Thigh-high TED stockings would be contraindicated because the top end of the TED hose will likely create shear on the anterior and inner thighs, where new skin grafts are still at risk of breaking open.

Question 26

An OTR® is evaluating an electrician who sustained an electrical burn in the right palmar area 2 days ago. The client has a subdermal burn in the middle of the palm with a full-thickness burn extended into the middle and index fingers. After completing the initial goniometric measurements of the right wrist and fingers, what other assessment is MOST IMPORTANT for the OTR to perform before developing an intervention plan?

A] Gross sensory screening
B] Edema measurement
C] Grip and pinch strength
D] Manual muscle testing

Answer 26

Solution: The correct answer is A.

For a client with an electrical burn, it is especially important to complete gross sensory screening of involved and uninvolved areas to identify the extent of peripheral sensory nerve involvement. For full-thickness and subdermal burns, it is likely that the peripheral sensory nerves are involved.

B, C: Although edema measurement and grip and pinch strength are important as baseline measurements, they might not be feasible in the early stage of subdermal and full-thickness burns because of bulky dressing.

D: Full manual muscle testing is not indicated unless the burns also involve the proximal arm area.

Question 27

A softball player sustained a deep partial-thickness burn to the anterior aspect of the right arm from the wrist, proximal to the ulnar styloid process, to the mid-upper arm. A split-thickness skin graft taken from the thigh was placed on the mid-forearm 3 days postinjury. When all the wounds are closed and the graft is stable, what is the BEST intervention to prevent hypertrophic scar development?

A] Jobst pressure sleeve with inserts
B] Elastic bandage wrapping from distal to proximal
C] Scar massage 3–5 times per day
D] Frequent PROM and AROM

Answer 27

Solution: The correct answer is A.

When most of the wounds are closed, a Jobst pressure garment is the best choice to prevent hypertrophic scarring. Adding inserts increases the effectiveness of compression therapy.

B: Elastic bandaging provides light compression and can initially be used when the wounds are not closed.

C, D: Scar massage and ROM activities are an important part of burn rehabilitation but are not interventions for preventing hypertrophic scars. The evidence supporting scar massage as an intervention for preventing scar hypertrophy is inconclusive.

Question 28

An OTR® is providing intervention to a medically stable client who sustained upper-extremity partial-thickness burns of the dominant arm, 5% of the total body surface area (TBSA), 2 days ago. Which intervention BEST represents a typical ADL intervention?

A] Instruct the client in the use of a long-handled spoon and fork and a built-up-handled knife for self-feeding.
B] Instruct the caregiver to assist the client in self-feeding and grooming tasks to prevent pain with movement.
C] Instruct the client in donning and doffing a pressure garment sleeve after applying lotion to the arm.
D] Encourage the client to independently self-feed without the use of adaptive equipment.

Answer 28

Solution: The correct answer is A.

A 5% TBSA burn in one of the upper extremities means that the client has approximately 50% surface area burns to the dominant upper extremity. Edema and bulky dressings in the early stage may interfere with the motion needed for ADLs, and short-term use of adaptive equipment would be indicated. Adaptation to environment and activity can facilitate the client’s achieving goals for independence in ADLs.

B: Allowing the caregiver to assist the client in ADLs does not encourage active participation in the early stage of recovery.

C: Scar management techniques such as applying lotion and using a pressure garment will not be needed until a later phase of rehabilitation.

D. Bulky dressings and pain will interfere with movement, and self-feeding may not be successful without use of an assistive device

Question 29

An OTR® is working with a client who received significant burns to the elbow. The client presents with a soft-tissue contracture at the elbow and is noncompliant with wear of an anterior elbow extension splint. What alternative would be BEST for effective treatment of the soft-tissue elbow contracture?

A] Ace wrap the splint on instead of using straps
B] Discharge the client from occupational therapy secondary to treatment noncompliance
C] Refer back to the plastic surgeon for surgery
D] Use serial casting to slowly stretch the tissue

Answer 29

Solution: The correct answer is D.

A cast is more difficult to remove and may promote better circumferential pressure to reduce hypertrophic scarring in addition to reducing the elbow contracture.

A: Ace wrapping a splint reduces edema, not contracture.

B: Discharging the client will not reduce the contracture.

C: Surgery is appropriate for a boney block contracture, but alternative treatment methods should be implemented for soft-tissue contractures before surgery.

Question 30

A softball player sustained a deep partial-thickness burn to the anterior aspect of the right arm from the wrist, proximal to the ulnar styloid process, to the mid-upper arm. A split-thickness skin graft taken from the thigh was placed on the mid-forearm 3 days postinjury. To minimize the risk of graft rejection in the initial phase (7 days postinjury), in what should the client be instructed?

A] Daily active pronation and supination exercises at least 5 times per day
B] Desensitization using ice to gently rub the burned areas from distal to proximal
C] Retrograde massage followed by elastic bandage wrapping from distal to proximal
D] Immobilization using the elbow extension splint and avoiding forearm movement

Answer 30

Solution: The correct answer is D.

During the initial phase after skin graft operation, it is important to maintain immobilization for 2–7 days or per the physician’s specific instruction.

A, B, C: Risk of graft rejection as a result of shear friction, movement, and excessive pressure should be avoided.

Question 31

An OTR® is treating an outpatient client who has sustained burns to the face, neck, and hands. Customized pressure garments are being fitted to reduce hypertrophic scarring. Which item cannot be used under the pressure garments to increase conformity to the skin?

A] A silicone gel sheet
B] A neoprene sheet
C] A silastic elastomer
D] A dynamic splint

Answer 31

Solution: The correct answer is D.

Dynamic splinting is primarily used to decrease soft-tissue contractures surrounding joints, not hypertrophic scarring of the skin, and splints are worn over the pressure garment, not under it.

A, B, C: Silicone gel sheets, neoprene sheets, and silastic elastomers can be used under pressure garments to increase pressure garment conformity to the skin.

Question 32

During the emergent phase of burn recovery, a patient with a full thickness burn is transferred for escharotomy. How might the OTR explain the procedure to the client?

a] The escharotomy procedure removes thick and raised scars that extend outside of the initial injury.
b] The escharotomy is surgical incision that helps to relieve pressure
c] The escharotomy will promote fluid intake and rapid healing to the site of the burn

Answer 32

B]

An escharotomy is a surgical incision that helps relieve pressure from the adherent dead tissue that forms on the skin following deep partial- or full-thickness burns. The escharotomy relieves interstitial pressure and restores circulation. Often edema, or swelling, develops after sustaining a burn, which can compress blood vessels, tendons, or nerves and may result in additional tissue damage and further complications.

The burn is an inelastic mass of burnt tissue, so the buildup of fluid or edema can put pressure on the blood vessels, tendons, and nerves. An escharotomy will help relieve the pressure.

Question 33

An outpatient OTR® is assessing a burn survivor, who reports having increasing difficulty in self-feeding because of difficulty in bending the right elbow. During PROM assessment, the client reports localized pain at the elbow when flexed more than 100°. The OTR feels a hard end feel at the elbow flexion. What is the BEST initial intervention?

Provide the client with low-load prolonged stretch using an elbow flexion splint.
Instruct the client in daily aggressive PROM at the elbow.
Instruct the client in a daily AROM program within the pain-free range.
Recommend the client use a long-handled swivel spoon for self-feeding.

Answer 33

Solution: The correct answer is C.

The client is developing heterotopic ossification at the right elbow. The best intervention is to preserve AROM. The heterotopic ossification should be confirmed with the client’s physician.

A, B: The client is developing heterotopic ossification at the right elbow. Use of a splint for sustained stretches and aggressive PROM are contraindicated for this condition.

D: The client is developing heterotopic ossification at the right elbow. The client may need adaptive equipment for self-feeding, but maintaining AROM should be the highest priority in the initial intervention.

Question 34

A 4-year-old client sustained full-thickness burns on the volar surfaces of both wrists and forearms 4 months ago. Despite using pressure garments and splinting for position, the child has developed thick scars across the wrists. AROM/PROM is as follows: Right flexion, 70/80; right extension, 25/40; left flexion, 70/85; left extension, 30/50. Which activity would be MOST EFFECTIVE in improving wrist mobility?

Finger painting on a vertical surface
Crawling through a tunnel maze
Playing a virtual reality bowling game
Throwing bean bags through vertical targets

Answer 34

Solution: The correct answer is B.

Because the burns are on the volar surface, the client has the most limitation in both active and passive wrist extension movement. Crawling is a developmental activity that can develop both flexibility and strength at the wrists through weight bearing.

A, C, D: Although these play activities may involve active wrist flexion and extension, crawling is the only activity that incorporates passive stretching through the occupation of play.

Question 35

A softball player sustained a deep partial-thickness burn to the anterior aspect of the right arm from the wrist, proximal to the ulnar styloid process, to the mid-upper arm. A split-thickness skin graft taken from the thigh was placed on the mid-forearm 3 days postinjury. The client would like to return to softball practice as soon as possible. What would be the BEST activity during the initial phase of outpatient rehabilitation?

Elbow extension splint 2 hours on, 2 hours off
Upper arm rehab bike for 30 minutes, twice daily
Scar massage followed by interactive, virtual-reality computer sports games
Wall pulley and wall ladder followed by skin care regimen

Answer 35

Solution: The correct answer is C.

Taking into consideration the client’s previous occupation as a softball player, virtual-reality computer sports games can involve similar sports movements and be motivating. However, because newly healed skin might split open as a result of overstretching or shearing force during movement, it is important to perform scar massage with a lubricant before activity.

A, B, D: These activities are preparatory activities that do not take into consideration the client’s areas of occupation.

Question 36

An OTR® is working in the burn unit of a hospital. A client has undergone skin grafting to close wounds on the dorsum of the hand. What occupational therapy treatment is MOST appropriate in the days immediately after the skin graft procedure?

Instruct client in AROM of the wrist and hand but limit PROM until the staples are removed
Fabricate and fit the client with a safe position splint
Involve the use of the grafted hand in ADLs
Perform PROM to the wrist and hand but instruct the client to limit use of the hand outside of occupational therapy treatment

Answer 36

Solution: The correct answer is B.

Splinting the hand in the safe position, typically for 5 to 7 days, allows the graft to take and the wound to heal and prevents deformities.

A, C, D: Once the skin has been grafted, the wrist and hand should be immobilized until the graft has adhered and staples are removed. No AROM, PROM, or functional use of the hand should occur during this time.

Question 37

An OTR® is treating a client who burned the bilateral lower extremities 10 days ago. The client refuses to participate in ADLs because of pain. The client rates the level of pain as 4 of 10 when resting in bed and 7 of 10 when standing. What is the BEST action for the OTR to take?

Report the client’s pain levels to the medical doctor and request stronger pain medication.
Apply an elastic bandage wrap for vascular support before getting the client out of bed.
Allow the client to perform ADLs while lying in bed, and focus on bed mobility skill.
Explain to the client that nonparticipation may lead to an early discharge from therapy.

Answer 37

Solution: The correct answer is B.

With lower-extremity burns, providing vascular support before standing decreases blood pooling in the lower extremity and therefore decreases pain in standing and ambulation. The client should learn an alternative strategy to manage pain early on in the intervention.

A: A nonpharmacological pain intervention should be attempted before requesting stronger pain medication.

C: Allowing the client to stay in bed does not allow for active participation in an upright posture and may lead to muscle wasting in the client.

D: Threatening the client with the consequence of nonparticipation usually does not address the main pain factor or motivate the client to participate.

Question 38

An OTR® is treating a client who sustained dorsal hand burns secondary to a work-related injury. In the rehabilitation phase of treatment, which technique for completing ROM of the hand is safest?

Passively range all digits and joints at once
Passively range each digit and joint one at a time
Instruct the client to actively make a fist, then straighten the fingers completely
Instruct the client to wear a resting hand splint at all times

Answer 38

Solution: The correct answer is B.

Ranging each joint separately decreases the chance of rupturing finger extensor tendons with dorsal hand burns.

A, C: AROM or PROM of more than one joint at a time increases the chance of a tendon rupture after a burn to the dorsal hand.

D: Wearing a splint inhibits the ability to perform PROM of the hand.

Question 39

A softball player sustained a deep partial-thickness burn to the anterior aspect of the right arm from the wrist, proximal to the ulnar styloid process, to the mid-upper arm. A split-thickness skin graft taken from the thigh was placed on the mid-forearm 3 days postinjury. What is the OPTIMAL intervention to prevent formation of elbow contracture?

A dorsal elbow flexion splint to position the elbow at 90 degrees flexion and the forearm in supination.
A volar elbow flexion splint to position the elbow at 90 degrees flexion and the forearm in neutral.
A dorsal elbow extension splint to position the elbow at extension and the forearm in neutral to supination.
A volar elbow extension splint to position the elbow at extension and forearm in neutral to supination.

Answer 39

Solution: The correct answer is C.

The antideformity position for the elbow is elbow extension and forearm in neutral to supination position.

A, B: Positioning the elbow in 90 degrees flexion will encourage contracture that will prevent elbow extension. Only a dorsal arm splint should be used because the burn area is in the anterior aspect of the arm.

D: Although the elbow should be in extension, only a dorsal arm splint should be used, because the burn area is in the anterior aspect of the arm.