The role of the physical therapist in wound care has evolved over the past several decades. For the physical therapist, the groundwork for learning wound and burn management occurs in the entry-level curriculum. Mechanisms of healing and systems reviews that enhance the knowledge base for caring for a child with open wounds or burns are taught. Physical therapists who desire to be active in wound management need to expand their knowledge through continuing education and, as with any specialty, competency-based training with a mentor. Pediatric clinicians need to be prepared to encounter a wide range of integumentary issues with children. Children are at risk for thermal injuries, pressure ulcers, and traumatic wounds. There are also specific congenital integumentary impairments that will challenge the pediatric clinician's ability to provide timely and age-appropriate interventions. This chapter will serve as an introduction to wound and burn management for the physical therapist as part of an interdisciplinary pediatric wound-management team.
Acute-care physical therapists play an integral role on the wound-management team. Therapists work closely with physicians and nurses to achieve wound closure using the various interventions that are discussed in this chapter. In the rehabilitation setting, the physical therapist faces challenges regarding management of chronic wounds and burns after the acute healing process or after grafting. Additionally, the physical therapist must address how the patient will achieve independence with functional skills. For example, in the outpatient setting, therapists are often called on to maximize function and to decrease activity or encourage participation limitations in situations involving open wounds. Therapists also intervene with scar management techniques after wound closure.
School-based therapists need to have background knowledge in the areas of wound and scar management because children with traumatic wounds, pressure ulcers, and burns will eventually return to school after their acute care and rehabilitation. Although school-based therapists may not provide direct wound care, other interventions usually need to be performed throughout the school day. Examples include using static or dynamic splints after a thermal injury, implementing pressure-relieving techniques for a child with a pressure ulcer, and reintegrating a child in school activities after an integumentary injury. Working with teachers and other classmates, the school-based therapist can assist in transitioning a child back to school after prolonged hospitalization. Such children may face issues surrounding cosmesis, body image, and peer acceptance.
Skin Structure and Function
The skin is the largest external organ of the human body, covering a surface area of 2 m2. To best understand the etiology of integumentary impairments, physical therapists need to know the anatomy and physiology of the skin. Its primary functions are sensation, metabolism, thermoregulation, and protection from trauma (Rassner, 1994). The skin has two primary layers, the epidermis and the dermis. A schematic drawing of the layers of the epidermis and dermis is shown in Figure 10-1.