| ICD-9-CM: |
| 945 - | Burn of Lower Limb(s) |
| 945.0 - | Burn of Lower Limb(s), Unspecified Degree |
| 945.00 - | Burn of Lower Limb(s), Unspecified Degree, Lower Limb [Leg], Unspecified Site |
| 945.01 - | Burn of Lower Limb(s), Unspecified Degree, Toe(s) (Nail) |
| 945.02 - | Burn of Lower Limb(s), Unspecified Degree, Foot |
| 945.03 - | Burn of Lower Limb(s), Unspecified Degree, Ankle |
| 945.04 - | Burn of Lower Limb(s), Unspecified Degree, Lower Leg |
| 945.05 - | Burn of Lower Limb(s), Unspecified Degree, Knee |
| 945.06 - | Burn of Lower Limb(s), Unspecified Degree, Thigh [Any Part] |
| 945.09 - | Burn of Lower Limb(s), Unspecified Degree, Multiple Sites of Lower Limb |
| 945.1 - | Burn of Lower Limb(s), Erythema [First Degree] |
| 945.10 - | Burn of Lower Limb(s), Erythema [First Degree], Lower Limb [Leg], Unspecified Site |
| 945.11 - | Burn of Lower Limb(s), Erythema [First Degree], Toe(s) (Nail) |
| 945.12 - | Burn of Lower Limb(s), Erythema [First Degree], Foot |
| 945.13 - | Burn of Lower Limb(s), Erythema [First Degree], Ankle |
| 945.14 - | Burn of Lower Limb(s), Erythema [First Degree], Lower Leg |
| 945.15 - | Burn of Lower Limb(s), Erythema [First Degree], Knee |
| 945.16 - | Burn of Lower Limb(s), Erythema [First Degree], Thigh [Any Part] |
| 945.19 - | Burn of Lower Limb(s), Erythema [First Degree], Multiple Sites of Lower Limb |
| 945.2 - | Burn of Lower Limb(s), Blisters, Epidermal Loss [Second Degree] |
| 945.20 - | Burn of Lower Limb(s), Blisters, Epidermal Loss [Second Degree], Lower Limb [Leg], Unspecified Site |
| 945.21 - | Burn of Lower Limb(s), Blisters, Epidermal Loss [Second Degree], Toe(s) (Nail) |
| 945.22 - | Burn of Lower Limb(s), Blisters, Epidermal Loss [Second Degree], Foot |
| 945.23 - | Burn of Lower Limb(s), Blisters, Epidermal Loss [Second Degree], Ankle |
| 945.24 - | Burn of Lower Limb(s), Blisters, Epidermal Loss [Second Degree], Lower Leg |
| 945.25 - | Burn of Lower Limb(s), Blisters, Epidermal Loss [Second Degree], Knee |
| 945.26 - | Burn of Lower Limb(s), Blisters, Epidermal Loss [Second Degree], Thigh [Any Part] |
| 945.29 - | Burn of Lower Limb(s), Blisters, Epidermal Loss [Second Degree], Multiple Sites of Lower Limb |
| 945.3 - | Burn of Lower Limb(s), Full-thickness Skin Loss [Third Degree NOS] |
| 945.30 - | Burn of Lower Limb(s), Full-thickness Skin Loss [Third Degree NOS], Lower Limb [Leg], Unspecified Site |
| 945.32 - | Burn of Lower Limb(s), Full-thickness Skin Loss [Third Degree NOS], Foot |
| 945.33 - | Burn of Lower Limb(s), Full-thickness Skin Loss [Third Degree NOS], Ankle |
| 945.34 - | Burn of Lower Limb(s), Full-thickness Skin Loss [Third Degree NOS], Lower Leg |
| 945.35 - | Burn of Lower Limb(s), Full-thickness Skin Loss [Third Degree NOS], Knee |
| 945.36 - | Burn of Lower Limb(s), Full-thickness Skin Loss [Third Degree NOS], Thigh [Any Part] |
| 945.39 - | Burn of Lower Limb(s), Full-thickness Skin Loss [Third Degree NOS], Multiple Sites of Lower Limb |
| 945.4 - | Burn of Lower Limb(s), Deep Necrosis of Underlying Tissues [Deep Third Degree] without Mention of Loss of a Body Part |
| 945.40 - | Burn of Lower Limb(s), Deep Necrosis of Underlying Tissues [Deep Third Degree] without Mention of Loss of a Body Part, Lower Limb [Leg], Unspecified Site |
| 945.41 - | Burn of Lower Limb(s), Deep Necrosis of Underlying Tissues [Deep Third Degree] without Mention of Loss of a Body Part, Toe(s) (Nail) |
| 945.42 - | Burn of Lower Limb(s), Deep Necrosis of Underlying Tissues [Deep Third Degree] without Mention of Loss of a Body Part, Foot |
| 945.43 - | Burn of Lower Limb(s), Deep Necrosis of Underlying Tissues [Deep Third Degree] without Mention of Loss of a Body Part, Ankle |
| 945.44 - | Burn of Lower Limb(s), Deep Necrosis of Underlying Tissues [Deep Third Degree] without Mention of Loss of a Body Part, Lower Leg |
| 945.45 - | Burn of Lower Limb(s), Deep Necrosis of Underlying Tissues [Deep Third Degree] without Mention of Loss of a Body Part, Knee |
| 945.46 - | Burn of Lower Limb(s), Deep Necrosis of Underlying Tissues [Deep Third Degree] without Mention of Loss of a Body Part, Thigh [Any Part] |
| 945.49 - | Burn of Lower Limb(s), Deep Necrosis of Underlying Tissues [Deep Third Degree] without Mention of Loss of a Body Part, Multiple Sites of Lower Limb |
| 945.5 - | Burn of Lower Limb(s), Deep Necrosis of Underlying Tissues [Deep Third Degree] with Loss of a Body Part |
| 945.50 - | Burn of Lower Limb(s), Deep Necrosis of Underlying Tissues [Deep Third Degree] with Loss of a Body Part, Lower Limb [Leg], Unspecified Site |
| 945.51 - | Burn of Lower Limb(s), Deep Necrosis of Underlying Tissues [Deep Third Degree] with Loss of a Body Part, Toe(s) (Nail) |
| 945.52 - | Burn of Lower Limb(s), Deep Necrosis of Underlying Tissues [Deep Third Degree] with Loss of a Body Part, Foot |
| 945.53 - | Burn of Lower Limb(s), Deep Necrosis of Underlying Tissues [Deep Third Degree] with Loss of a Body Part, Ankle |
| 945.54 - | Burn of Lower Limb(s), Deep Necrosis of Underlying Tissues [Deep Third Degree] with Loss of a Body Part, Lower Leg |
| 945.55 - | Burn of Lower Limb(s), Deep Necrosis of Underlying Tissues [Deep Third Degree] with Loss of a Body Part, Knee |
| 945.56 - | Burn of Lower Limb(s), Deep Necrosis of Underlying Tissues [Deep Third Degree] with Loss of a Body Part, Thigh [Any Part] |
| 945.59 - | Burn of Lower Limb(s), Deep Necrosis of Underlying Tissues [Deep Third Degree] with Loss of a Body Part, Multiple Sites of Lower Limb |
| A burn is injury to body tissue caused by exposure to heat (flame, scalding liquids, steam), chemicals, electricity, friction, or radiation. Burns compromise the normal ability of skin tissue to prevent loss of heat and water and to protect the body from infection. Blood circulation also may be compromised, resulting in cell damage within skin layers and eventual tissue death (necrosis) in the burned area. Burns are extremely complex and interfere with body metabolism and the functioning of major organ systems.
Burns of the legs and feet most commonly occur from exposure to steam, flames, hot liquids, chemicals, or electricity. The lower limbs, including the feet, represent 36% of the total body surface area (TBSA) in adults. Burns of the leg will be evaluated for depth and amount of surface area damaged to determine burn severity and appropriate therapy. The extent of tissue damage is expressed as a percentage of the TBSA and may be further classified as major, moderate, or minor. An assessment method called “the rule of nines” allows physicians to quickly estimate the surface area of the burn and related risk. Head and neck represent 9%, upper limbs are each 9%, anterior and posterior trunk each represent 18%, anterior and posterior portions of the lower limbs are each 9% and external genitalia are 1%.
Age is an important factor in burn outcomes because epidermal thickness varies with age, influencing depth of injury. Young children and elderly individuals, for example, have thinner layers and are at greater risk of full-thickness burns.
Burns are characterized as first-, second-, third, or fourth-degree according to depth of injury. First-degree burns affect only the outermost layer (epidermis) of the skin, causing redness without blistering. Tissue damage is minor and the protective functions of the skin remain intact. Sunburn is an example of a first-degree burn.
Second-degree burns, also called partial-thickness burns, damage the outer epidermis and the underlying tissue layer (dermis). Partial-thickness burns can be either superficial or deep depending on the extent of damage. Blistering is the most notable sign of second-degree burn; fluid-filled blisters usually will be seen on a pink, moist and soft burn area. Blisters usually heal without scarring and require only minor treatment. Second-degree burns are most often caused by scalds from hot liquids, hot oil, grease spills, or short exposure to flames.
Third degree, or full thickness burns, damage or destroy the deepest layers of skin including the dermis, its nerve endings, and fatty connective tissue of the subcutaneous layer. Because nerve endings have been destroyed, these burns may be pale and produce little pain initially. Skin damage from a third-degree burn will result in significant scarring and abnormal bending and stiffening (contractures) of affected joints. These burns are caused by flames, immersion scalds, chemical exposures, and electrical injuries and are classified as severe.
Fourth-degree burns are even more severe, affecting the epidermis, dermis and subcutaneous layers, as well as underlying muscle tissue and bone. Tissue damage and impaired circulation may be irreversible and can require extensive surgical removal of dead and damaged tissue (débridement) and reconstruction. Fourth-degree burns sometimes result in loss of limbs. They usually result from longer exposure to the same thermal sources as third-degree burns.
The skin acts as a protective barrier against bacteria, fungi, and viruses. Burns damage that protective function and also damage local immune system cells (Langerhans cells), affecting immune system functioning and leaving the individual vulnerable to local and systemic infection until the burn heals. The skin also plays a vital role in temperature regulation, and its extensive vascular network is an important blood reservoir. The effect of burn damage on these functions can cause heat loss, impede blood flow and coagulation, and increase inflammatory response in the burn area.
Severe burns also result in significant loss of body fluids leading to dehydration and electrolyte imbalances that can, in turn, affect heart function, blood pressure, and circulation.Incidence and Prevalence: An estimated 700,000 Americans are treated for burns each year at emergency departments; 45,000 are admitted to hospitals or burn centers (Goodis; Edlich). The highest incidence of burn injuries occurs in individuals between ages 20 and 29 years and in children younger than age nine; more serious burns occur in males (67%) than in females, and 25% of burn injuries are work-related (Edlich). |
Source: Medical Disability Advisor
| History: The individual usually will report pain except in third-degree burns in which nerve endings are damaged. The history will include the cause of the burn, the age and health status of the individual, and other injuries sustained. Physical exam: Physical findings vary with burn severity. Depth and size of the burn indicate severity, including redness with no blistering for first-degree burns, large blisters on legs and feet in second-degree burns, pale skin and tissue swelling (edema) in third-degree burns, and deep injury extending into muscle or bone in fourth-degree burns. Severely affected tissue may be blackened and leathery or range in color from white or brown to bright red.
Entrance and exit wounds may be seen in electrical burns. When high-voltage electrical current passes through the body, small, deep holes may be found at the point where it first makes contact, most often the feet. Electrical burns to the legs may not produce noticeable changes in the outer layer of skin, but severe underlying damage to muscle and bone tissue may be present, as well as interrupted blood flow. Tests: Laboratory tests usually are not needed for diagnosing first- and second-degree burns. Diagnostic evaluation for deeper, more severe burns may include a complete blood count (CBC), blood urea nitrogen (BUN), blood glucose, electrolytes (sodium, potassium and chloride), coagulation tests, and blood gases. Other laboratory tests may include urinalysis to determine fluid status and serum myoglobin to evaluate muscle destruction. Imaging studies may be performed to evaluate suspected muscle and bone damage. Fiberoptic bronchoscopy may be done for suspected inhalation injury.
When burns occur as the result of exposure to fire, blood carboxy-haemoglobin (COHb) levels should be checked. If results are greater than 60%, the outlook is very poor. At lower levels, hyperbaric oxygen therapy may be life-saving, since oxygen at three atmospheres reduces the half life of COHb to about 20 minutes, and dissolves sufficient oxygen in the plasma to maintain life. |
Source: Medical Disability Advisor
| Emergency treatment for first- and second-degree burns may begin by rinsing the burned area and, in the case of a chemical burn, removing contaminated clothing. Constricting clothing and jewelry must be removed promptly to avoid a "tourniquet effect" that can develop as edema increases. If the individual has been exposed to flame or a structure fire, potential airway inhalation injury will be evaluated and may require intubation or CPR to provide adequate oxygen intake. Moderate and severe burns require intravenous fluid replacement. Tetanus boosters are given routinely and, depending upon severity, nonsteroidal anti-inflammatory drugs (NSAIDs) or intravenous opioids may be given to relieve pain. In first- and second-degree burns, cool compresses are applied to the burn site to relieve pain. The burn wound often requires débridement, washing, and, when the skin is broken, covering with an antibiotic ointment.
Damage from electrical burns is proportionate to the intensity of the current (amperage). Electric shock may result in cardiac and respiratory arrest, requiring immediate cardiopulmonary resuscitation. Deep electrical burns increase the need for fluid replacement and also increase risk of renal failure.
In third- and fourth-degree burns, intravenous fluid replacement is needed to prevent shock and maintain cardiac output. In the first 24 hours, the initial fluid intake is typically 4 mL/kg of body weight per percent of body surface area burned. A Foley catheter may be inserted in the bladder to measure urinary output and to help monitor fluid replacement needs.
Edema sometimes develops under dead tissue in the burned area (eschar). This is of special concern in lower limb burns because there is little space in the circumference of a leg or foot into which fluid can be absorbed. A “tourniquet effect” caused by edema can block venous and arterial blood circulation, causing dramatic increases in tissue pressure within the affected limb. Nerves in the limb also may be compressed, compounding the problem. To release fluid pressure, the physician may make an incision through the overlying tissue (escharotomy or fasciotomy). Vascular circulation to the affected limb can be monitored manually by measuring pulses or mechanically with a Doppler flow meter. Pain and color changes in surface tissue are not always reliable indicators of circulation in lower limb burns.
Burn cases resulting from fires may require use of a hyperbaric chamber that administers oxygen at higher than normal atmospheric pressure to the individual to treat carbon monoxide and/or cyanide exposure and to enhance oxygenation of damaged tissue. Infection is the leading cause of death in hospitalized burn patients. Surgical removal (excision) of infected tissue often is required. Radical excision of muscle or even complete or partial amputation of the leg or foot may be necessary if lack of blood flow has resulted in death of tissue (ischemia) or if bone and tissue have been destroyed.
Based on the extent and depth of the burn, the emergency physician will determine whether the individual requires the special care of a burn center of which there are 125 in the US. The American Burn Association recommends transfer to a burn center for second-degree burns covering over 10% TBSA; third-degree burns covering over 5%; second-degree or third-degree burns involving critical areas such as major joints, feet, hands, or face; burns with associated inhalation injury; and electrical or lightning burns. Burn centers typically perform serial operations on individuals with severe or third-degree burns. One or more operations to débride dead tissue may be followed by skin grafting or by surgical placement of temporary skin substitutes. Skin grafting is frequently the final stage, although some burns require scar revisions to improve range of motion.
Burned feet present specific therapeutic problems because of their relatively poor blood supply and therefore greater risk for infection. Foot function may be compromised by burn-related contractures, deformities, or loss of tissue on the bottom of the foot. Newer treatment approaches use a temporary skin substitute to increase healing, protect the wound, and decrease pain. Severe foot burns may require immediate débridement of the dead tissue followed by replacement with healthy skin from the individual (skin graft). When the individual is able to walk, shoe padding or custom footwear may provide extra comfort for the burned area.
Long-term care will address infection prevention, associated psychological trauma, and nutritional support. A severe burn destroys protein (amino acids) and may result in drastic weight loss during recovery, requiring up to 9000 calories per day to maintain energy balance. Reconstructive orthopedic surgery or plastic surgery may be done to improve mobility of legs and feet. Long-term rehabilitation may also be needed. |
Source: Medical Disability Advisor
| Uncomplicated first- and second-degree burns of the lower limb generally heal uneventfully. Severe lower limb burns may result in permanent disfigurement and scarring, loss of mobility, amputation, or death. General prognosis depends on depth and extent of the burn, the individual’s age, other injury associated with the burn, and comorbid conditions.
Most fire deaths are caused by inhalation of smoke or toxic substances rather than by burns. Of deaths attributed specifically to burns, most are the consequence of exposure to flame; burns by scalding represent the second highest number of deaths. Survival rates for burn patients have improved steadily over the past two decades with improved firefighting techniques, advances in topical antibiotic therapy for wounds, earlier excision and grafting, more effective management of burn shock, and improved emergency response and intensive care management in burn centers. |
Source: Medical Disability Advisor
| The goals of rehabilitation are a return to pre-injury levels of strength, ambulation, cardiovascular endurance, range of motion (ROM), and activities of daily living (ADL). In addition, rehabilitation plays an important role in minimizing scar formation, controlling edema, and reducing the risk of secondary impairments. Active patient participation is crucial to a successful outcome.
To achieve those goals, the therapist will tailor established modalities to suit the individual’s requirements. These include massage, pressure dressings, positioning, splinting, and a progressive program of active and passive exercise.
Massage helps to return suppleness to burned tissue by breaking down adhesions and new scar tissue. Additionally, the therapist may select from a variety of pressure dressings to reduce scarring and edema as well as to enhance circulation to skin grafts. Dressings include a variety of elastic wraps, tubular support bandages, and pressure garments. Generally, pressure garments are reserved to prevent contractures or the need for skin grafting. Burned areas are usually maintained in an elongated or neutral position to avoid further tissue destruction and to control edema. Splinting is often useful to support positioning, and can be removed for range of motion exercise.
A program of exercise corresponding to normal range of motion begins as soon as the individual is able. Ideally, this would be on the first day unless it interferes with the establishment of newly grafted skin. As the individual improves, the therapist will add appropriate strengthening and endurance regimens. Before discharge, the burn team unit should provide the patient with a program of skin care, positioning, and exercise to be followed at home. Follow-up monitoring and modification are essential. |
Source: Medical Disability Advisor
| Most minor burns to the lower limbs cause no complications. However, more serious burns may result in infection, uncontrolled edema, scarring, contraction tissue that restricts movement, and interrupted circulation, especially in the feet. Emergency escharotomy may be performed to relieve edema in burned legs or feet. Eschars may tighten enough to interrupt blood supply to tissue, result in tissue death and loss of feet or toes. If underlying muscle has been destroyed in a burned limb, oxygen-carrying protein (myoglobin) can enter the blood stream and result in kidney damage. Young children, the elderly, and immunocompromised individuals are at higher risk of developing complications from burns. |
Source: Medical Disability Advisor
| Work restrictions and accommodations vary depending on the site and severity of the burn. Limitations are usually minor or unnecessary for minor burns of the lower limbs. Severe burns may require several months of time off for recovery and surgical procedures. The individual may require compressive dressings for several months to minimize scar formation and for comfort. The lower limbs are often weak or stiff, and full function may be permanently lost. Lower limb amputation may require special job accommodations. Frequent follow-up appointments often accompany burns of the legs and feet, and the individual may require adaptive equipment to accommodate lower limb debility. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Did the burn involve thermal, chemical, electrical, or ultraviolet radiation injury?
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Was the burn first-, second-, third-, or fourth-degree?
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What percentage of body surface area was burned?
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What other associated burns or injuries occurred?
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Was pulmonary function compromised by inhalation injury?
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Is arterial and venous circulation in the limb now normal?
Regarding treatment:
- Were shock and circulatory dysfunction avoided by adequate fluid replacement?
-
Was airway inhalation injury (if present) treated?
-
For more severe burns, was excision and grafting performed?
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Was repeated débridement of the burn area required?
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Was nutritional support provided during healing?
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Was a program of splinting and exercise prescribed to prevent abnormal bending of joints (contractures)?
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Has individual begun a physical rehabilitation program?
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Is individual compliant with rehabilitation?
Regarding prognosis:
- Did infection develop? If so, was individual compliant with antibiotic treatment?
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Are underlying conditions present that could prevent healing and prolong recovery?
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How severe is scar formation or contracture?
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Was amputation necessary? If so, how will this affect the daily activities of individual?
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Would individual benefit from psychological and occupational therapy?
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Is individual actively engaged in ongoing rehabilitation program?
|
Source: Medical Disability Advisor
| American Burn Association. 13 Feb. 2009 <http://www.ameriburn.org>.Cohen, Richard, Brent Moelleken, and . "Disorders Due to Physical Agents." Current Medical Diagnosis & Treatment. 43rd ed. New York: McGraw-Hill, 2004. 1534-1537. Edlich, R. F., M. L. Martin, and W. Long. "Thermal Burns." Rosen's Emergency Medicine: Concepts and Clinical Practice. Ed. J. A. Marx. 6th ed. Philadelphia: Mosby Elsevier, 2006. 11365-1368. Goodis, Jamie, and Erik Schraga. "Burns, Thermal." eMedicine. Eds. Debra Slapper, et al. 29 Oct. 2008. Medscape. 13 Feb. 2009 <http://emedicine.medscape.com/article/769193-overview>. |
Source: Medical Disability Advisor
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