OBJECTIVES

   This case study aims to discus, explain, and establish an understanding of the disease
process. In addition, it will also include the care management (nursing or medical management)
applicable to the condition. At the end of this case study, the students aim to acquire more
knowledge regarding the condition, enhance their skills in terms of developing nursing
processes, and develop their attitude associated with managing the condition. 
Specifically, this case study aims to:

1.     To learn about the disease process associated with burn injury.

2.     To define and determine the causes, risk factors, clinical manifestations, diagnostic tests,
and nursing/medical management of the disease process.
3.     To gather new knowledge in terms of research and studies associated with the disease
process.
4.     To describe the structures and functions of the affected organs (skin, thorax, lungs,
kidney, upper limbs, lower limbs muscles, and abdomen.)
5.     To trace the pathophysiology of the disease process.
6.     To use the nursing process as a framework for care of the patient with burn injury.
7.     To determine the action, indications, contraindications, side effects, and the nursing
responsibility of the medications appropriate for the disease condition.
8.     To provide a complete and thorough physical assessment of the patient.
9.  To evaluate the results of the laboratory examinations and determine the appropriate
nursing responsibilities.
10.     To determine the history of the client’s condition.
 
INTRODUCTION
Burns are potentially devastating injuries with many consequences ranging from
physical, functional, and occupational to cosmetic and psychosocial damage. It is a tissue
damage caused by heat, chemicals, electricity, sunlight, or nuclear radiation. The most common
burns are those caused by hot liquid or steam, building fires, and flammable liquids and gasses.
Burn Mechanisms:

 Heat — The depth of the thermal injury is related to contact temperature, duration of
contact of the external heat source, and the thickness of the skin. Because the thermal
conductivity of skin is low, most thermal burns involve the epidermis and part of the
dermis. The most common thermal burns are associated with flames, hot liquids, hot solid
objects, and steam.
 Electrical discharge — Electrical energy is transformed into heat as the current passes
through poorly conducting body tissues. Electroporation (injury to cell membranes)
disrupts membrane potential and function. The magnitude of the injury depends on the
pathway of the current, the resistance to the current flow through the tissues, and the
strength and duration of the current flow.
 Friction — Injury from friction can occur due to a combination of mechanical disruption
of tissues as well as heat generated by friction.
 Chemicals — Injury is caused by a wide range of caustic reactions, including alteration
of pH, disruption of cellular membranes, and direct toxic effects on metabolic processes.
 In addition to the duration of exposure, the nature of the agent will determine injury
severity. Contact with acid causes coagulation necrosis of the tissue, while alkaline burns
generate liquefaction necrosis. Systemic absorption of some chemicals is life-threatening,
and local damage can include the full thickness of skin and underlying tissues.
 Radiation — Radio frequency energy or ionizing radiation can cause damage to skin and
tissues. The most common type of radiation burn is the sunburn. Radiation burns are
most commonly seen today following therapeutic radiation therapy and are also seen in
patients who receive excessive radiation from diagnostic procedures.

Burns are defined by how deep they are and how large an area they cover. A large burn
injury is likely to include burned areas of different depths. Deep burns heal more slowly, are
more difficult to treat, and are more prone to complications such as infections and scarring. Very
deep burns are the most life-threatening of all and may require amputation. Types of burns
include:

 First-degree burns damage the outer layer (epidermis) of the skin. These burns usually
heal on their own within a week. A common example is a sunburn.
 Second-degree burns damage not only the outer layer but also the layer beneath it
(dermis). These burns might need a

 skin graft—natural or artificial skin to cover and protect the body while it heals—and
they may leave a scar.
 Third-degree burns damage or completely destroy both layers of skin including hair
follicles and sweat glands and damage underlying tissues. These burns always require
skin grafts.
 Fourth degree burns extend into fat, fifth degree burns into muscle, and sixth degree
burns to bone.

Burn injuries are under-appreciated injuries that are associated with substantial morbidity
and mortality. Burn injuries, particularly severe burns, are accompanied by an immune and
inflammatory response, metabolic changes and distributive shock that can be challenging to
manage and can lead to multiple organ failure. Of great importance is that the injury affects not
only the physical health, but also the mental health and quality of life of the patient. Accordingly,
patients with burn injury cannot be considered recovered when the wounds have healed; instead,
burn injury leads to long-term profound alterations that must be addressed to optimize quality of
life. Burn care providers are, therefore, faced with a plethora of challenges including acute and
critical care management, long-term care and rehabilitation.
 

REVIEW OF RELATED LITERATURE

Burns

Burns, as define by the World Health Organization (WHO), is an injury in the skin or
other organic tissue resulting from exposure to heat or due to radiation, radioactivity, electricity,
friction, or contact with chemicals.  It is known to be one of the most common types of traumas
around the world with over 11 million cases that needs medical attention and approximately
180,000 deaths in the world annually. In addition to this, 90% of burns occurs withing low- or
middle-income countries where availability of specialist for acute and long-term care for burns
are limited. Furthermore, women and children are more likely to sustain burn injuries inside the
home where as men are more likely to sustain them in a work setting or during outdoor
recreational activities.

According to Masood et. al (2016) burn injury happens once some or all the cells within
the skin or tissues area unit is broken by hot flame, solids and liquids. Additionally, the
complications of the injury vary up to a great extent depending on the affected location, tissue
and the degree of severity. Furthermore, systemic and local both type of complications is caused
by burn. Fluid loss and breakdown of skin integrity is major contributor of systemic
complications. Contractures, scarring and eschars are the local complications of burn injury. The
risk of developing systemic complications is directly proportional to the total body surface
area (TBSA) involved in burn injury. Following are the risk factors of severe systemic
complications and mortality. In addition to that, eschar “rigidness and death of tissue
caused by deep burns”. Respiration can be compromise by an eschar around the thorax
and viability of limbs and digits is endangered by ischemia.

Douglas, Dunne, and Rawlins (2017), stated that Patients with small superficial burns
may be managed in the emergency department with appropriate first aid, analgesia, cleaning of
the burn, debridement of blisters and the application of a dressing. However, patients with large
burns will be transferred to a burns center for continued resuscitation, critical care and wound
management. Appropriate fluid resuscitation aims to ensure that all tissues are perfused
adequately and the burn is not allowed to ‘extend’ or deepen due to hypovolemia and
hypotension. Similarly, fluid resuscitation should not be excessive and contribute to an already
edematous state, as increasing edema prevents adequate blood flow to the wound that is trying to
heal. Furthermore, burnt arms and legs should be elevated above the level of the heart.
Physiotherapy in the form of active and passive range of movement exercises is essential for
maintenance of strength, joint mobility and to reduce edema. Moreover, patients with burns over
10-15% BSA require dietary support to reduce the catabolic effects of the burn injury and
maintain immune function. Nasogastric feeds or supplemental protein shakes can be used to
supplement oral diet. Patients with very large burns, airway or inhalational injuries may require
intensive care support.

Thoracic Drainage

         Major burn injuries can have local and systemic effects in the body. Such effects on the
pulmonary system is pneumothorax. As stated by Daley (2020), the presence of air or gas in the
pleural cavity is referred to as pneumothorax (i.e., the potential space between the visceral and
parietal pleura of the lung). The clinical outcome is determined by the degree of lung collapse on
the afflicted side. The insertion of a chest tube or thoracic drainage is one of the therapeutic
options for pneumothorax. A chest tube is a flexible plastic tube that is inserted into the pleural
space or mediastinum via the chest wall. It is used to remove air from the intrathoracic space in
the event of pneumothorax, or fluid from the intrathoracic space in the case of pleural effusion,
blood, chyle, or pus when empyema develops.
         The chest tube is attached to a closed chest drainage system, which allows air or fluid to
be drained while keeping air or fluid out of the pleural area. The system is airtight to prevent
ambient pressure from entering. Because the pleural cavity is generally under negative pressure,
allowing for lung expansion, any tube linked to it must be sealed so that no air or liquid may
enter the area where the tube is attached. There are different types of chest drainage systems.
These are one-bottle system, two-compartment system and three-compartment system/traditional
chest drainage system.  Among these systems, the traditional chest drainage is the most common.

The traditional chest drainage system typically has three chambers; the collection
chamber, water-seal chamber and wet or dry suction control chamber. The chest tube connects
directly to the collection chamber, which collects pleural cavity drainage. The chamber has
been calibrated to measure drainage. The chamber's exterior surface contains a "write-on"
surface for recording the date, time, and amount of fluid. This chamber is normally located on
the system's far right side. Following that, the water-seal chamber features a one-way valve that
enables air to depart the pleural cavity during exhale but does not allow it to re-enter during
inhalation due to chamber pressure. To guarantee effective operation, it should be filled with
sterile water and kept at the 2 cm mark, and it should be checked on a regular basis. The water in
the water-seal chamber should rise with inhale and descend with exhale (a phenomenon known
as tidaling), indicating that the chest tube is patent. Continuous bubbling might be an indication
of an air leak, and modern systems incorporate a leak measurement system – the higher the
number, the worse the air leak. Intrathoracic pressure can also be measured using the water-
seal chamber. Finally, to provide consistent suction for the patient, the dry suction system
employs a self-controlled regulator that regulates the amount of suction and responds to air
leakage. Suction is not required for all patients. If a patient is given suction, a wet suction system
is normally regulated by the amount of water in the suction control chamber, which is typically
set at -20 cm for adults. There is less suction when there is less water. The quantity of suction
varies with the patient and is regulated by the chest drainage system rather than the suction
source.

As with any medical procedure, thoracic drainage also has its complications. The
complications of chest tube placement are respiratory distress, air leak, accidental removal of
chest tube, accidental disconnection, bleeding at insertion site, subcutaneous emphysema,
drainage suddenly stops and sudden increase in bright red drainage. Depending on the institution,
the incidence of these problems ranges from 1% to 10%. Smaller chest tubes have been
introduced over the last two decades, which are not only easier to install but also cause
substantially less discomfort than previous chest tubes. (Ravi & McKnight, 2021)

Continuous Renal Replacement Therapy

         Continuous renal replacement therapy (CRRT) is a widely used treatment for critically ill
patients with acute kidney damage, particularly those who are hemodynamically unstable. In the
therapy of the critically sick patient with kidney failure, many methods of renal support may be
employed. CRRT, conventional intermittent hemodialysis (IHD), and prolonged intermittent
renal replacement treatments (PIRRTs), which are a hybrid of CRRT and IHD, are among them.
All of them utilize essentially comparable extracorporeal blood circuits and differ largely in
terms of therapy duration and, as a response, the speed of net ultrafiltration and solute clearance.
Furthermore, dialysis therapies rely heavily on diffusive solute clearance, whereas convection is
used to remove solutes during hemofiltration.

         As studied by Hanafusa, 2015, while first conceived as an arteriovenous treatment, the
majority of CRRT is now conducted utilizing pump-driven venovenous extracorporeal circuits.
Although this adds some complexity, such as pressure monitors and air detectors, the pump-
driven venovenous circuit delivers greater and more continuous blood flows while eliminating
the risks associated with extended arterial cannulation with a large-bore catheter. Several
methods for administering CRRT have been devised. The treatment is known as slow
continuous ultrafiltration when used just for volume management. More commonly, CRRT
provides both solute clearance and volume removal when delivered as continuous venovenous
hemofiltration (CVVH), continuous venovenous hemodialysis (CVVHD), or continuous
venovenous hemodiafiltration (CVVHDF), with the differences between these modalities
relating to the mechanisms for solute clearance.

         As with all medical interventions, CRRT is not without its risks. Starting CRRT
necessitates the installation of a large-bore central venous catheter, which may need to be kept in
place for an extended period of time. Vascular or visceral damage leading in bleeding,
pneumothorax, hemothorax, and arterio-venous fistula development are among well-known
consequences of catheter insertion. Long-term catheter usage is linked to venous thrombosis or
stenosis. Blood exposure to the extracorporeal circuit may result in acute allergy or delayed
immunologic responses as a result of cytokine activation. If air is trapped into the circuit beyond
the return line air detector, air embolization can occur during catheter insertion or removal, as
well as at any moment during treatment.

         Circuit clotting is the most prevalent problem during CRRT, and the most common cause
of circuit clotting is insufficient catheter performance, which results in flow restriction and
pressure alarms that block blood flow. If a blood flow rate of 200 to 300 mL/min cannot be
maintained, a catheter replacement should be performed as soon as possible. Excessive filtration
fraction can cause hemoconcentration inside the hemofilter, which can contribute to filter
clotting. If there is no catheter failure, blood flow is maximized, and the filtration percentage is
greater than 20%, anticoagulation should be initiated or intensified. Complications of heparin
anticoagulation might include bleeding and heparin-induced thrombocytopenia. Citrate
anticoagulation may cause citrate toxicity due to citrate buildup, overt hypocalcemia due to
insufficient calcium replacement, and both metabolic acidosis and metabolic alkalosis.
Electrolyte abnormalities (hypophosphatemia, hyponatremia, hypernatremia, hyperkalemia) and
hypotension are other typical consequences. (Tandukar, S., & Palevsky, P. M., 2019).

As stated by Bosslet, et al (2015), issues related to the clinical and ethical appropriateness
of initiation or continuation of RRT often occur in patients with acute kindey injury (AKI).
Discussions of initiation and discontinuation of therapy with patients and/or their
family/surrogate decision-makers should be framed in light of the overall prognosis and goals of
care, and need to consider other life-sustaining treatments in addition to RRT. To enable the
process of shared decision-making, it is critical that both the primary management service and
the nephrology specialists supervising the RRT give a uniform evaluation of prognosis and
treatment choices, delivered in a straightforward yet empathetic manner. The high mortality rate
of AKI in the setting of critical illness, as well as the complicated and highly emotional features
of decisions about commencing or withdrawing renal assistance, imply that early participation of
palliative care services may be beneficial.

Escharotomy

         Zhang et. al (2021) stated in their study that early surgical intervention by doing
escharotomy can prevent these detrimental consequences and improve the outcome of the
patient. Escharotomy, as defined in the study, is an emergency surgical procedure involving
incising through areas of burnt skin to release the eschar and its constrictive effects, restore distal
circulation, and allow adequate ventilation. Furthermore, escharotomies often are performed as
part of a burn victim's resuscitation care, and the decision is made based on clinical assessments
of the patient and their response to treatment provided before that assessment. Generally, an
escharotomy is performed when full circumferential thickness (and sometimes partial thickness)
burns result in circulatory or respiratory compromise. Moreover, it is usually performed within
the first 48 hours of injury, due to initial injury from the primary source, and secondarily due to
resuscitation and development of tissue edema.

         Tam and Luo (2019) mentioned in their study that, early excision of the burn eschar has
been one of the most significant advances in modern burn care. As early as in 1920s, people
recognized the importance to remove early the necrotic and denatured tissues in the burn wound
treatment, and gradually this method became the main treatment way of deep burn wounds.
Additionally, the early escharotomy or tangential excision of deep burn wounds can be
divided into three types, i.e., primary stage, prompt stage, and early stage. The primary stage
means the surgery is carried out within 24 hours after burn injury. The prompt stage refers to 24–
72 h after burn, while the early stage refers to 3–5 days. Moreover, extensive total escharotomy
on severe burn patients at within or around 24 hours after burn injury, which achieved good
outcome not only in wound healing but also in decreasing incidences of different complications
and mortality. This method is still used in clinical practice in some burn centers. It is necessary
to evaluate carefully the general status, especially the circulation stability, before this kind of
operation.
 ANATOMY & PHYSIOLOGY

A. Skin

The skin is the largest organ of the body, with a total area of about 20 square feet. The skin
protects us from microbes and the elements, helps regulate body temperature, and permits the
sensations of touch, heat, and cold. 

Skin has three layers:

1. Epidermis, the superficial layer made up keratinized stratified squamous epithelium that
provides a waterproof barrier and creates our skin tone. It does not have any blood
vessels within it.

Most of the skin can be classified as thin skin, which has four layers of. From deep to
superficial, these layers are the stratum basale (basal layer), stratum spinosum (spinous
layer), stratum granulosum (granular layer), and stratum corneum (cornified layer). While
the “thick skin” is found only on the palms of the hands and the soles of the feet. It has a
fifth layer, called the stratum lucidum, located between the stratum corneum and the
stratum granulosum

Most cells of the epidermis are keratin-producing cells or keratinocytes. Keratinocytes

produce keratin, a tough, protective protein that makes up the majority of the structure of
the skin, hair, and nails. The keratinocytes in the stratum corneum are dead and regularly
slough away, being replaced by cells from the deeper layers. The entire epidermis is
replaced every 30 to 40 days. The renewal process becomes slower with age but faster in
injured skin, when cell proliferation is accelerated for wound healing.

2. Dermis is a connective tissue layer of mesenchymal origin located deep to the epidermis
and superficial to the subcutaneous fat layer. It contains blood and lymph vessels, nerves,
and other structures, such as hair follicles and sweat glands. The dermis is made of two
layers of connective tissue that compose an interconnected mesh of elastin and
collagenous fibers, produced by fibroblasts.

Two layers:

a. The papillary dermis is the superficial layer, lying deep to the epidermis. The papillary
dermis is composed of loose connective tissue, which means the collagen and elastin
fibers of this layer form a loose mesh. This superficial layer of the dermis projects into
the stratum basale of the epidermis to form finger-like dermal papillae.
b. The reticular layer is the deep layer, forming a thick layer of dense connective tissue that
constitutes the bulk of the dermis. This layer is well vascularized and has a rich sensory
and sympathetic nerve supply.

3.   Hypodermis is the deeper subcutaneous tissue made of fat and connective tissue. It is not part
of the integumentary system. It is just a fatty layer underneath the dermis that help our body
warm. b
 Hair Follicle

The hair follicle is a tube-shaped sheath that surrounds the part of the hair that is under the skin
and nourishes the hair. It is located in the epidermis and the dermis. The hair shaft is the part of
the hair that is above the skin. Hair is a keratinous filament growing out of the epidermis. It is
primarily made of dead, keratinized cells.

Sweat Glands

When the body becomes warm, sudoriferous glands produce sweat to cool the body.
Sweat glands develop from epidermal projections into the dermis and are classified as merocrine
glands; that is, the secretions are excreted by exocytosis through a duct without affecting the
cells of the gland.

Two types of sweat glands:

a. An eccrine sweat gland is a type of gland that produces a hypotonic sweat for thermoregulation.
These glands are found all over the skin’s surface, but are especially abundant on the palms of
the hand, the soles of the feet, and the forehead

b.    An apocrine sweat gland is usually associated with hair follicles in densely hairy areas, such as
armpits and genital regions. Apocrine sweat glands are larger than eccrine sweat glands and lie
deeper in the dermis, sometimes even reaching the hypodermis.

Sebaceous Gland

Is a type of oil gland that is found all over the body and helps to lubricate and waterproof
the skin and hair. Most sebaceous glands are associated with hair follicles. They generate and
excrete sebum, a mixture of lipids, onto the skin surface, thereby naturally lubricating the dry
and dead layer of keratinized cells of the stratum corneum. The fatty acids of sebum also have
antibacterial properties, and prevent water loss from the skin in low-humidity environments.

B.    Thorax

The thoracic wall is composed mainly of the ribs, the sternum and the thoracic muscles.

a. The ribs are arc-shaped, flat bones that protect thoracic organs such as the heart and
lungs, and provide attachment points to muscles of the back, chest and proximal upper
limb. They are 12 pairs of ribs, attached posteriorly to the thoracic vertebrae.

The ribs can be divided into groups based on their distal attachment points. The first seven
pairs of ribs articulate directly with the sternum through their costal cartilages and are known as
the true ribs or vertebrosternal ribs. The 8th-10th ribs unite anteriorly via their costal cartilages
and articulate indirectly with the sternum via the 7th rib; they are known as false ribs or
vertebrocostal ribs. The 11th and 12th ribs are known as floating ribs as they do not attach to the
sternum in any manner and are particularly short and have no necks nor tubercles.
 b.  The sternum is a flat, elongated bone located centrally in the anterior thoracic wall. It’s made
up of three main parts: the manubrium, body and xiphoid process. It articulates with the
clavicles at the sternoclavicular joints and with the cartilages of the first seven pairs of ribs
through the sternochondral/sternocostal joints. The sternum anchors the right and left ribs to
stabilize the rib cage, and has various functions including the protection of the heart and
lungs from mechanical damage.

c.  The muscles of the thoracic wall are defined as muscles attached to the bony framework of
the thoracic cage. They maintain the stability of the thoracic wall, and play a role in
respiration. The muscles of the thoracic wall include the following muscle groups:

  Serratus posterior muscles

  Levatores costarum muscles
  Intercostal muscles
 Subcostal muscles
 Transversus thoracis muscles 

C.    Lungs

The lungs are the major organs of the respiratory system, and are divided into sections, or
lobes. The right lung has three lobes and is slightly larger than the left lung, which has two lobes.

The lungs are separated by the mediastinum. This area contains the heart, trachea, esophagus,
and many lymph nodes. The lungs are covered by a protective membrane known as the pleura
and are separated from the abdominal cavity by the muscular diaphragm.

With each inhalation, air is pulled through the windpipe (trachea) and the branching
passageways of the lungs (the bronchi), filling thousands of tiny air sacs (alveoli) at the ends of
the bronchi. These sacs, which resemble bunches of grapes, are surrounded by small blood
vessels (capillaries). Oxygen passes through the thin membranes of the alveoli and into the
bloodstream. The red blood cells pick up the oxygen and carry it to the body's organs and tissues.
As the blood cells release the oxygen, they pick up carbon dioxide, a waste product of
metabolism. The carbon dioxide is then carried back to the lungs and released into the alveoli.
With each exhalation, carbon dioxide is expelled from the bronchi out through the trachea.

D.    Kidney

The kidneys are the primary functional organ of the renal system. They are essential in
homeostatic functions such as the regulation of electrolytes, maintenance of acid–base balance,
and the regulation of blood pressure. They serve the body as a natural filter of the blood and
remove wastes that are excreted through the urine.

They are also responsible for the reabsorption of water, glucose, and amino acids, and will
maintain the balance of these molecules in the body. In addition, the kidneys produce hormones
including calcitriol, erythropoietin, and the enzyme renin, which are involved in renal and
hematological physiological processes.
 The kidneys are bean-shaped, reddish brown paired organs, located behind the abdomen and
on either side of the spine.

There are three major regions of the kidney:

a.   Renal cortex - The kidneys are surrounded by a renal cortex, a layer of tissue that is also covered
by renal fascia (connective tissue) and the renal capsule.

b.    Renal medulla - The medulla is the inner region of the parenchyma of the kidney.

The medulla consists of multiple pyramidal tissue masses, called the renal pyramids, which are
triangle structures that contain a dense network of nephrons.

c.    Renal pelvis - The renal pelvis contains the hilium. The hilum is the concave part of the bean-
shape where blood vessels and nerves enter and exit the kidney; it is also the point of exit for the
ureters—the urine-bearing tubes that exit the kidney and empty into the urinary bladder.

Blood filtration and urine formation take place in the nephrons, the functional units of the
kidneys. Within each nephron, the glomerulus filters the blood, allowing smaller molecules and
debris (filtrate) to pass through, and into the renal tubule, while keeping larger molecules and
cells inside the blood vessels. As the filtrate travels through the renal tubule, necessary
substances such as nutrients and water are returned to the blood. Additional waste is also
secreted into the filtrate. At that point, the filtrate has become urine, and it flows through the
collecting duct, into the renal pelvis, and out through the ureter.
 

E. Upper Limbs

The upper limb is divided into 4 main parts - shoulder, arm, forearm and hand. The shoulder
contains two important regions: the deltoid region and the axillary (armpit) region. The arm and
forearm contain two regions each that correspond to their anterior and posterior surfaces. Found
between the arm and forearm are the anterior and posterior cubital regions. Below the forearm is
the carpal region, which connects the forearm with the hand. Lastly, the hand consists of the
palm anteriorly, and dorsum of the hand posteriorly. The hand can be subdivided into the
metacarpal region and the digits. The digits are numbered 1-5 from the thumb to the little finger.

a.   The shoulder is where the upper limb attaches to the trunk. Its most important part is the
glenohumeral joint; formed by the humerus, scapula and clavicle. The shoulder joint is
reinforced with two groups of muscles, superficial and deep. Superficial muscles include the
deltoid and the trapezius, whereas the deep group contains the supraspinatus, infraspinatus, teres
minor and subscapularis muscles.

b.  The arm is the area between the shoulder and the elbow. The muscles are grouped into anterior
and posterior compartments by the septa that attach to the humerus. The anterior compartment
contains the coracobrachialis, brachialis and biceps brachii muscles. While the posterior
compartment contains only one muscle, the triceps brachii.
c.   The forearm has twenty muscles, and two bones (radius and ulna). When in anatomical position
(supination), the radius is found laterally while the ulna is medially in the forearm. The muscles
of the forearm are grouped into anterior and posterior compartments, with the anterior
compartment containing mostly flexors, and the posterior, extensors. The anterior
compartment contains superficial, intermediate and deep layers, whilst the posterior
compartment contains superficial and deep layers.

d.  The hand is probably the finest product of human evolution from the aspect of our body
mechanics. The intrinsic muscles of the hand are the: palmaris brevis, interossei (palmar and
dorsal), adductor pollicis, thenar, hypothenar and lumbrical muscles.

Basic parts of the hand

• the wrist (carpus)

• the metacarpus

• the digits

F.  Lower Limb Muscles

Muscles of the hip and thigh

The hip muscles encompass many muscles of the hip and thigh whose main function is to act on
the thigh at the hip joint and stabilize the pelvis. Without them, walking would be impossible.
They can be divided into three main groups:

     Iliopsoas group

> 

    Gluteal muscles
    Hip adductors

Muscles of the leg

The primary function is to produce the movements on the ankle joint.

  Anterior compartment
  Lateral compartment
  Posterior compartment

Muscles of ankle and foot

 Central muscles of the sole of the foot

 Lateral muscles of the sole of the foot
 Medial muscles of the sole of the foot
    Dorsal muscles of foot 

G.  Abdomen

The abdomen is the lower part of the anterior trunk, located right below the thorax. The
abdomen is divided into several regions that allow for precise communication about the location
of anatomical structures within it, as well as any pathologies. There are two ways to categorize
the abdomen. The first divides the regions into four quadrants, while the second and more
common way, divides it into nine regions.

The anterolateral muscles are those that compose the front and the sides of our abdomen.
There are five muscles in this group (deep to superficial): transversus abdominis, internal
abdominal oblique, rectus abdominis, external abdominal oblique, and pyramidalis muscles.

The posterior abdominal muscles are those that compose the back portion of your abdomen.
The posterior group consists of one true posterior wall muscle, the quadratus lumborum, as well
as the iliopsoas muscle group which continues into the lower limb.

These muscles not only compose the walls of the abdomen, but they also support the
abdominal viscera and participate in the formation of important anatomical passageways that
allow structures from the abdomen and pelvis to reach the perineum and lower limb