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Case Study Burn Injury

Case Study Burn Injury: 1-6
PLEASE IN OWN WORDS, if any references used please provide citation in paragraphs and reference page.

Jennie, a 28 year old female, was involved in a motor vehicle accident on her way to work. She is a RN at the local acute care hospital. Jennie sustained partial thickness and full- thickness burns on her arms and chest. In addition to her burn injuries, Jennie sustained a left femur fracture and a left humeral fracture.

Jennie has undergone multiple surgeries and grafts to address the burn injuries. Orthopedic surgeons completed an Open Reduction Internal Fixation (ORIF) of her femur and an ORIF of her humerus.

Jennie is admitted to your short term rehab facility with the following orders:
OT evaluate and Treatment:
no weight bearing to left Upper extremity
Toe touch weight bearing left Lower extremity

1. What is the difference between partial thickness and full-thickness burns?

2. What type of splinting and compression garments may be part of healing and contracture management?

3. Jennie's MD orders Passive Rang of motion, Active assist range of motion to bilateral digits, wrist, and elbows and right shoulder. What are factors that may effect ROM activities?

4. What can Jennie do outside of "treatment time" to increase function?

5. What are some things to consider to assist with a safe discharge home?

6. Discuss impact of acute pain with rehabilitation process.

List references.

Solution Preview

Hi,

Let's take a closer look at this interesting and complex case of Jenny. I also provided some extra information at the end of this response.

RESPONSE:

1. What is the difference between partial thickness and full-thickness burns?

The difference is determined by the depth of the burn. The dermis is 15 - 40 times thicker than the epidermis. As a result, the seriousness of a partial thickness (or dermal) burn depends on how much of the dermis has been injured. A deep and large partial thickness burn will usually be treated with skin grafting, whereas a partial thickness burns usually leave scars. In contrast, a full thickness burn destroys all three layers of skin, resulting in the loss of not only the skin but also the hair follicles, sweat glands, and the region where new skin cells are formed. Thus, full thickness burns require skin grafts. In terms of treatment, when partial thickness or full thickness burns exceed thirty percent of an adult's total body surface area, it is usually necessary to perform grafts in stages because the patient does not have enough healthy skin to graft the burned area in a single operation (About Burn Injuries).

2. What type of splinting and compression garments may be part of healing and contracture management?

Jenny had an ORIF and it could be stabilized with a plate and screws (or rod or nail), which often results in a stabilized fracture that should heal with little complications. If the ORIF used a rod or nail, it is much more complex. The nail is inserted on the superior aspect of the head of Jenny's humerus. To accomplish this, the rotator cuff tendons are split and sewn back together. Jenny's rehabilitation is then limited by the healing rate of the rotator cuff tendon.

Initially, for the ORIF on her humerus, for post-operative positioning, Jenny's arm would probably be placed on a cushion, elevated position. Extra support might include an upper arm splint or sling.

For burns, pressure garments may be used to control the amount of hypertrophic scarring. After scar tissue begins to form, garments that put pressure on the scar are often used. Some scars grow beyond or above the area of the wounded skin (known as hypertrophic scarring). While the reasons this occurs are not fully understood, keeping pressure on the scar as it forms helps reduce. In the past traction was used. However, Traction as a treatment option has many drawbacks, including poor control of the length and alignment of the fractured bone, development of pulmonary insufficiency, deep vein thrombosis, and joint stiffness due to supine positioning (Burn Treatments).

The type of splinting that might be part of healing and contraction management for the immobilization of femur is the Sager Splint, which is best if the patient has a proximal fracture of the Femur the most common type of femoral fracture) (Sager, n.d).

3. Jennie's MD orders Passive Rang of motion (ROM), Active assist range of motion to bilateral digits, wrist, and elbows and right shoulder. What are factors that may affect ROM activities?

Pain is one factor that might affect ROM activities (Aukerman, 2006), often controlled with pain medications. Other factors that affect fracture healing and ROM activities include the type of fracture, degree of trauma, systemic and local disease, and infection (Buckley, 2007) (see table at http://www.emedicine.com/Orthoped/topic636.htm).

The type of fracture and the type of ORIF method (plate and screws or with an intermedullary (IM) rod or nail) also can impact the ROM activities. In the ORIF, the rotator cuff tendons are split and sewn back together, so ROM activities and rehabilitation is then limited by the healing rate of the rotator cuff tendon (Edell, 2006).

Two other factors that affect ROM are: whether there is damage to the radial nerve and the amount of nerve impingement (Edell, 2006).

To add to this, the amount of nerve damage, presence of scar tissue and swelling affects ROM activities and the recovery rate. If there is nerve damage, for example, the nerve will heal at the rate of approximately 1 mm per month. In 75% - 90% of the patients treated with a closed reduction, full recovery will occur in 3 to 4 months (Edell, 2006).

EXTRA INFORMATION:

Damage to the radial nerve occurs (estimated) up 18% of all humerus fractures involve damage to the radial nerve. Due to this, many humerus fractures show signs of radial nerve entrapment upon initial examination. Radial nerve palsy results in the inability to extend the wrist and fingers as seen in the picture. Return to normal range of motion, and return of full strength usually takes 3 to 6 months for this type of injury. This depends upon the amount of nerve damage, presence of scar tissue and swelling. Nerves will heal at the rate of approximately 1 mm per month. If after 3 - 4 months the nerve palsy is still present, surgical exploration of the nerve may be necessary. This surgery will focus on determining the cause of the nerve impingement (Edell, 2006).

Another factor is the type ORIF that might also impact ROM activates. Jenny's fracture was complex in nature, and open reduction with internal fixation (ORIF) surgery was necessary. This can be accomplished in one of two methods depending on the severity of the injury. One way is to use a plate and screws or with an intermedullary (IM) rod or nail. Both methods of internal fixation are very invasive and have potential complications ...

Solution Summary

In reference to the case study, this solution addresses the questions. It explains the difference between partial thickness and full-thickness burns and the type of splinting and compression garments that may be part of healing and contracture management. In the scenario, Jennie's MD orders: Passive Rang of motion, Active assist range of motion to bilateral digits, wrist, and elbows and right shoulder; it discusses the factors that may effect ROM activities. It also discusses what Jennie can do outside of "treatment time" to increase function. It then discusses some things to consider to assist with a safe discharge home. Finally, it discusses the impact of acute pain with rehabilitation process. References in APA format

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