Burns Management: Classification, Rule of Nines & Splinting

Burns rehabilitation is a critical area in physiotherapy exams. Questions focus heavily on calculating Total Body Surface Area (TBSA) using the Rule of Nines and knowing the correct anti-deformity positions (Splinting) to prevent contractures.

1. Classification of Burns (Depth)

Burns are classified based on the depth of tissue damage. The deeper the burn, the higher the risk of scarring and contracture.

Degree	Layer Involved	Appearance & Sensation	Healing Time
1st Degree (Superficial)	Epidermis only.	Red, Dry, Painful. No blisters. (e.g., Sunburn).	3-7 days. No scar.
2nd Degree (Superficial Partial Thickness)	Epidermis + Upper Dermis (Papillary).	Red, Blisters present, Wet, Very Painful.	7-21 days. Minimal scar.
2nd Degree (Deep Partial Thickness)	Epidermis + Deep Dermis (Reticular).	White/Red, Dry, Less Painful (nerve damage).	>21 days. High risk of hypertrophic scar.
3rd Degree (Full Thickness)	Epidermis + Dermis + Subcutaneous fat.	Leathery, White/Black (Eschar), Painless (nerves destroyed).	Requires Grafting.
4th Degree	Involves Muscle, Tendon, Bone.	Charred appearance.	Requires Flap surgery/Amputation.

[Image of burn classification layers]

2. Wallace Rule of Nines

This is the standard method for calculating TBSA (Total Body Surface Area) burned in adults. This calculation is vital for fluid resuscitation (Parkland Formula).

[Image of rule of nines diagram]

Adult Values

• Head & Neck: 9% (Front 4.5% + Back 4.5%)
• Upper Limbs: 9% each (Front 4.5% + Back 4.5%)
• Trunk (Front): 18% (Chest 9% + Abdomen 9%)
• Trunk (Back): 18% (Upper Back 9% + Lower Back 9%)
• Lower Limbs: 18% each (Front 9% + Back 9%)
• Genitalia (Perineum): 1%
• Total: 100%

Pediatric Variation: In children, the head is larger relative to the body.
Child Head: 18%
Child Legs: 14% each
Exam Trick: For every year of age over 1, subtract 1% from the head and add 0.5% to each leg.

3. Splinting & Anti-Deformity Positioning

The "Position of Comfort" is usually the "Position of Contracture." Physiotherapists must position the patient in the opposite direction of the potential contracture.

Burn Site	Potential Contracture	Correct Splinting Position
Anterior Neck	Flexion (Chin to chest)	Extension / Hyperextension (No pillow under head, use towel roll under neck).
Axilla (Armpit)	Adduction	Abduction (90°) with External Rotation. (Use Airplane Splint).
Elbow	Flexion	Extension.
Hand (Dorsum burn)	Claw Hand	Intrinsic Plus Position (Wrist Ext 30°, MCP Flex 70-90°, IP Ext).
Hip	Flexion & Adduction	Extension & Abduction (Prone lying helps).
Knee	Flexion	Extension.
Ankle	Plantarflexion (Foot drop)	Neutral (90° Dorsiflexion) using AFO or footboard.

4. Skin Grafts: Basics

When a burn cannot heal on its own (Deep 2nd or 3rd degree), skin is transplanted.

• Autograft: Skin taken from the patient's own body (Donor site) to the burn (Recipient site). Permanent.
• Allograft (Homograft): Skin from another human (cadaver). Temporary cover.
• Xenograft (Heterograft): Skin from another species (e.g., Pig). Temporary.

Types of Autografts

• Split Thickness Skin Graft (STSG): Epidermis + part of Dermis. Meshed to cover large areas. Heals faster but contracts more.
• Full Thickness Skin Graft (FTSG): Epidermis + entire Dermis. Less contraction, better cosmetic result. Used for face/hands.

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Frequently Asked Questions (FAQs)

Q1: What is the "Intrinsic Plus" position?

It is the safe position for splinting a burned hand. The wrist is extended, MCP joints are flexed, and IP joints are extended. This prevents collateral ligament shortening and "Claw Hand" deformity.

Q2: Why is the axilla splinted in abduction?

The axilla is prone to adduction contracture (skin webbing) because patients naturally hold their arms close to their body for pain relief. The "Airplane Splint" keeps the arm abducted to prevent this.

Q3: How do I calculate TBSA if only the front of one arm is burned?

Using the Rule of Nines: The entire arm is 9%. The front (anterior) half is 4.5%. So, the answer is 4.5%.

Exam Quiz: Burns & Plastic Surgery (10 MCQs)

Test your knowledge. Click the correct option to see the answer and reasoning.

1. According to the Rule of Nines, an adult with burns on the entire Right Arm and the entire Anterior Trunk has a TBSA of:

Correct Answer: C
Right Arm = 9%. Anterior Trunk (Chest + Abdomen) = 18%. Total = 9 + 18 = 27%.

2. Which position is recommended to prevent contracture in a patient with Anterior Neck burns?

Correct Answer: B
Anterior neck burns tend to pull the chin down (flexion contracture). Extension is required to counteract this. Pillows are contraindicated.

3. Blisters and severe pain are characteristic of which degree of burn?

Correct Answer: A
Superficial 2nd-degree burns involve the upper dermis, leaving nerve endings exposed (pain) and causing fluid accumulation (blisters).

4. An "Airplane Splint" is used for burns in which area?

Correct Answer: D
The airplane splint holds the arm in abduction to prevent axillary adduction contractures.

5. Which type of skin graft involves the epidermis and the entire thickness of the dermis?

Correct Answer: B
FTSG contains the full dermis. It provides better cosmetic results and contracts less than STSG but requires a well-vascularized bed.

6. A 3rd-degree burn is typically:

Correct Answer: C
Full-thickness burns destroy the nerve endings in the dermis, rendering the area painless (anesthetic) to touch.

7. The "Intrinsic Plus" position for the hand involves:

Correct Answer: A
This position keeps the collateral ligaments of the MCP joints taut and prevents the "Claw Hand" deformity common in dorsal hand burns.

8. In the Rule of Nines for an infant (baby), the head represents approximately:

Correct Answer: B
Infants have a much larger head-to-body ratio than adults. The head is 18%, while legs are only 14% each.

9. A graft taken from a pig to cover a human burn wound is called:

Correct Answer: C
Xenograft (Heterograft) is tissue taken from a different species. It is used as a temporary biological dressing.

10. The primary goal of positioning and splinting in the acute phase of burns is:

Correct Answer: A
Burn scars contract as they heal. Positioning tissues in an elongated state counteracts this force to preserve range of motion.

References

1. Serghiou, M. A., et al. (2010). Clinical Practice Guidelines on Burn Care. American Burn Association.
2. O'Sullivan, S. B., & Schmitz, T. J. (2016). Physical Rehabilitation. F.A. Davis.
3. Settle, J. A. D. (1996). Principles and Practice of Burns Management. Churchill Livingstone.