# Burns Physiotherapy > Burns physiotherapy in Physiotherapy: rule of nines, anti-deformity positioning, splinting, mobilisation, scar management and pressure garment protocols. - Canonical URL: https://prepelephant.com/topics/allied/physiotherapy/burns-physiotherapy - Exam / course: Allied Health · Subject: Physiotherapy - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-02 - Last updated: 2026-10-02 - How to cite: "Burns Physiotherapy", PrepElephant, https://prepelephant.com/topics/allied/physiotherapy/burns-physiotherapy ## Direct answer Rehabilitation of a burn starts on day one, not when the wound closes: by the end of the first week, a burned neck held comfortable in flexion is already contracting into one. Assessment begins with extent and depth — the rule of nines for adults (head and neck 9 per cent, each upper limb 9, anterior trunk 18, posterior trunk 18, each lower limb 18, perineum 1) modified for children whose heads are proportionally larger, with the child's palm method adding roughly 1 per cent per palmar surface — because fluid resuscitation, referral and prognosis all hang on those numbers. Physiotherapy then runs three parallel programmes: anti-deformity positioning and splinting against the contracture pattern each site predicts, early range-of-motion and strengthening work, and long-term scar management with pressure garments worn about 23 hours daily for 12 to 18 months, plus silicone gel and massage once healed. ## What you must remember - **Rule of nines (adult):** head and neck 9%, each arm 9%, anterior trunk 18%, posterior trunk 18%, each leg 18%, perineum 1%; in infants the head takes about 18-19% and each leg about 7% at birth, converging toward adult values with age — Lund and Browder charts handle the years between. - **Depth classification:** epidermal (erythema, blanches, heals in about a week), superficial partial (blistering, moist, painful, heals 2-3 weeks), deep partial (mottled, reduced sensation, often needs grafting beyond 3 weeks), full thickness (white/leathery/charred, painless, cannot heal without grafting). - **Anti-deformity positions by site:** neck in extension (no pillow, mattress edge or roll under the shoulders); shoulder at 90° abduction (avoid pillows in the axilla — splints instead); elbow in extension; wrist 20-30° extension with MCPs flexed about 70-90° and IPs extended (the "safe position" of the hand); hip in extension with abduction, knee in extension, ankle in neutral dorsiflexion. - **Timing truth:** position and passive range begin day 1; exercise continues through dressing changes (often the best analgesic-timed session); splinting supplements, never replaces, movement. - **Scar management protocol:** custom pressure garments delivering commonly quoted pressures around 20-25 mmHg (some references higher), worn 23 hours a day for 12-18 months, initiated once wounds are closed; silicone gel sheets; friction massage to remodel and desensitise. - **Complications to preempt:** hypertrophic scarring and contracture, heterotopic ossification near the elbow, pulmonary complications after inhalation injury, and deconditioning. ## The first fortnight of a 30 per cent flame burn A 26-year-old woman with flame burns across the anterior trunk, right axilla, neck and both hands — roughly 30 per cent by the rule of nines — begins physiotherapy while still in the intensive phase. Day one priorities are positioning: no pillow, a roll behind the shoulders for neck extension, the right shoulder splinted at 90 degrees abduction so the axilla cannot heal closed, and both hands splinted in the safe position between sessions. Twice daily, analgesia is timed so that passive and active movement through full range happens while the medication peaks — a session skipped for "pain" is a contracture scheduled. Inhalation injury adds chest physiotherapy, humidification and incentive spirometry. As grafts take, exercise pauses over graft sites for the days the surgeon specifies, then resumes cautiously; by week three she sits out, stands, and walks the ward with compression bandages shaping the grafts. Discharge planning starts early: pressure garments measured at the burn clinic, night splint wear, massage and mobility, and review every few weeks for a year — the scar, not the wound, is the disease she will live with. ## What exams test — and the Indian angle Theory papers ask for the rule of nines, burn depth classification, and principles of physiotherapy management — marks are lost by answers that begin rehabilitation "after healing"; day-one positioning is the exam-correcting sentence. Short notes recycle pressure garments, anti-deformity positioning of the hand, and the safe position splint; viva panels probe why the neck is extended without a pillow and why axillary pillows are avoided (they hold the burn in its contracture position while feeling kind). Indian answers gain from the epidemiology: kitchen scalds and flame burns dominate, contractures present late because specialist centres are distant, and releasing surgery followed by committed rehabilitation is often the realistic pathway — acknowledging post-burn contracture surgery reads as clinical experience rather than textbook recitation. ## Frequently asked questions ### How is burn extent estimated in adults? By the rule of nines — head and neck 9%, each upper limb 9%, anterior and posterior trunk 18% each, each lower limb 18%, perineum 1% — with Lund and Browder charts preferred for children. ### What is the anti-deformity position for a burned hand? Wrist extended 20-30 degrees, metacarpophalangeal joints flexed about 70-90 degrees, and interphalangeal joints extended — the safe position, maintained by splint between exercise sessions. ### Why do pressure garments follow burn healing? Sustained pressure of roughly 20-25 mmHg worn 23 hours daily for 12-18 months flattens and remodels hypertrophic scarring, with effectiveness depending on adherence. ### When should mobilisation begin after a burn? On day one — positioning, passive and active range of motion start immediately, timed with analgesia, pausing only over fresh grafts for the days the surgeon specifies. ### Which burn depths require grafting? Deep partial-thickness burns unlikely to heal within about three weeks and all full-thickness burns, since the dermal elements needed for spontaneous healing are destroyed.