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ORIGINAL ARTICLE
Year : 2016  |  Volume : 24  |  Issue : 1  |  Page : 29-35

Management of postburn contractures of upper extremities: A general surgeon's perspective


Department of Plastic Surgery and General Surgery, Dr D Y Patil Medical College, Pimpri, Pune, Maharashtra, India

Date of Web Publication12-Dec-2016

Correspondence Address:
Bharat Bhushan Dogra
Department of Plastic Surgery, Dr D Y Patil Medical College, Pimpri, Pune - 411 018, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-653X.195524

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  Abstract 

Introduction: Postburn contracture (PBC) is one of the common sequelae encountered after burns in general surgical practice. Surgical management of such deformities involves release of contracture followed by cover by skin graft or skin flap. Optimum management of PBCs has always been a challenge to the surgeon because of paucity of adequate healthy skin in the affected areas. Various operative techniques are available, and the surgeon has to decide which particular technique will be more suitable for a particular patient. We have employed the techniques of release by Z-plasty, and release and skin grafting in managing PBC involving upper extremity, and this study is based on our experience with these techniques. Aims and Objective: The study was carried out to evaluate the frequency of different PBCs involving upper extremities and comparing the relatively simpler techniques of release of contracture and cover by skin grafting and Z-plasty, which can be undertaken by a general surgeon as well. Materials and Methods: A total of 100 cases having PBC of upper extremities of more than 6 months duration were included in this study. Complex contractures of hands involving tendons and joints were excluded from this study. Linear contractures were managed by single or multiple Z-plasty techniques whereas patients having wider and dense scars were managed by release/excision of scar and cover by skin grafting. Observations: The mean visual analog score for patient satisfaction was 8.06 for Z-plasty group versus 5.33 for split skin grafting (SSG) group. The mean stay for patients who had undergone Z-plasty was 9.40 days as compared to 15 days for SSG. Conclusion: Contracture release with local flap cover was better technique in relation to patient satisfaction, recurrence of deformity, hospital stay, and time taken for rehabilitation.

Keywords: Full-thickness skin grafting, postburn contracture, split skin grafting, Z-plasty


How to cite this article:
Dogra BB, Kataria M, Kandari A, Ahmed S, Singh A, Virmani R. Management of postburn contractures of upper extremities: A general surgeon's perspective. Indian J Burns 2016;24:29-35

How to cite this URL:
Dogra BB, Kataria M, Kandari A, Ahmed S, Singh A, Virmani R. Management of postburn contractures of upper extremities: A general surgeon's perspective. Indian J Burns [serial online] 2016 [cited 2017 Sep 21];24:29-35. Available from: http://www.ijburns.com/text.asp?2016/24/1/29/195524


  Introduction Top


Burn trauma constitutes the second most common cause of trauma-related deaths after road traffic accidents.[1] Although survival of a person having sustained extensive burns is the immediate concern of a treating physician, the restoration to preinjury status is more desirable. Burns of the upper extremity may severely limit function by making job performance difficult or sometimes impossible. Inadequate splinting and rehabilitation after burn injuries invariably result in debilitating postburn contractures (PBCs) that impair functional abilities of the involved limb. Superficial burns may not produce functional deformity, but deep second-degree or third-degree burns usually produce deformity after immediate treatment. Moreover, if proper application of splints and pressure garments is not employed by the patient, debilitating contractures result. The ultimate aim of management is to ensure preinjury quality of life.[2] The choice of surgical procedure must be individualized in every patient. Therapeutic measures include skin grafting, Z-plasty, and flaps, which may be local, distant, or rarely microvascular performed by a reconstructive surgeon. However, reconstructive surgeon may not be available in a peripheral/district hospital, where many of burn casualties report to a general surgeon for management. Hence, this study was undertaken by a general surgery resident under the supervision of a reconstructive surgeon in a teaching hospital for clinical evaluation of all cases of PBCs affecting the upper extremities and to evaluate relatively simpler technique of skin grafting and Z-plasty in managing such cases.


  Materials and Methods Top


This study was undertaken between July 2012 and September 2014 in 100 patients having PBCs of upper extremities who were admitted in the surgical department of a teaching hospital. Pro forma included demographic data, duration of contracture, site and type of contracture, severity of deformity, surgical technique employed, and time taken for rehabilitation.

Inclusion criteria

All cases of PBCs affecting upper extremity reporting in the surgical outpatient department (OPD) were included in the study.

Exclusion criteria

  • Complex postburn deformities of the hand involving tendons and joints
  • PBCs of duration <6 months where scar was not yet matured.


Method

All the patients enrolled in the study were clinically evaluated regarding extent and severity of contracture. Nature of scar and deformity produced over shoulder, elbow, wrist, and hand was noted, and movements at various joints were evaluated preoperatively, postoperatively, and subsequently during follow-up.

Patients were counseled regarding the surgery to be performed. Z-plasty procedure was carried out if the contracture was found to be a linear band with healthy skin around the contracture band. However, if the patient had a broad, dense-scar contracture, it was released/excised to achieve correction.

Meticulous hemostasis was achieved followed by covering the raw area by skin graft. Tie-over dressing was done in all such cases, and correction was maintained by Plaster-of-Paris splint application in corrected position till skin graft got consolidated. Full-thickness skin graft (FTSG) was used after the release of contracture affecting palm or working surface of digits. Z-plasty was also employed for release of web contracture.

Split skin graft (SSG) was harvested from thigh, and FTSG was harvested from groin crease area.

First dressing was changed on postoperative day 5, followed by dressings on alternate days till skin graft got consolidated. Patients undergoing Z-plasty technique stayed in hospital till removal of sutures and cases managed by skin grafting stayed in hospital till graft got consolidated. Follow-up was carried out every 15 days on OPD basis for 2 months, followed by monthly basis till 6 months. After achieving healing of the operated part, patients were advised to apply coconut oil (moisturizer) over donor and recipient areas twice a day and to use pressure garments regularly for almost 23 h/day for 6 months.

After correction of contractures involving axillary region, patients were advised to apply night splints to maintain 90° abduction at shoulder. Elbows were maintained in full extension, wrists in 30° dorsiflexion and for hand, metacarpophalangeal joints in 90° flexion, and interphalangeal joints in full extension. Patients were encouraged to move the affected joints and apply pressure garments.

Visual analog score (VAS) was recorded for patient satisfaction at the time of discharge and later visits. During follow-up, each patient was assessed for correction of deformity, ability to perform daily routine activities, and fitness to resume duties at his/her workplace. Duration of hospital stay and time taken for rehabilitation was recorded for comparative evaluation.


  Observations Top


Type of contracture

Out of 100 cases of PBCs, 23 cases had axillary contractures (23%). Details of the site and type of contracture are detailed in [Graph 1].



Thirteen of these contractures were found to be involving anterior or posterior axillary folds (56.52%), and rest of ten patients had contractures involving axillary dome as well (43.47%) [Figure 1] and [Figure 2]. Axillary contractures were classified as type-1, where anterior or posterior axillary fold was involved, type 2 where both anterior and posterior axillary folds were involved but sparing the dome, and type 3, those obliterating the axilla.[3]
Figure 1: Preoperative axillary contracture

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Figure 2: Postoperative axillary contracture correction

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Elbow region was affected in 17 cases (17%), and in 16 of these, flexor aspect was involved (94%) whereas extensor aspect was affected in only one patient (6%) [Figure 3] and [Figure 4]. The contractures affecting elbow region were classified based on extensor lag. Cases having extensor lag up to 45° were considered mild, those having extensor lag of 45–90° were labeled moderate, and elbow contracture resulting in extensor lag beyond 90° was considered severe.
Figure 3: Preoperative elbow contracture

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Figure 4: Postoperative elbow contracture correction

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The wrist area was involved in 20 cases (20%), and in 16 of them, flexor aspect was affected (80%). Only four patients had involvement of the extensor aspect (20%) [Figure 5] and [Figure 6].
Figure 5: Preoperative wrist contracture

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Figure 6: Postoperative wrist contracture correction

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As many as 46 patients (46%) had contractures involving various digits of the hand. Forty-four of them were in the flexor aspect (95.65%), and extensor aspect was found to be involved in two cases (4.34%) [Figure 7] and [Figure 8]. Six patients had contractures at more than one site.
Figure 7: Preoperative digits contracture

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Figure 8: Postoperative digits contracture correction

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Type of surgery

We carried out the following surgical procedures depending on the site, size, and nature of scar contracture:

  • Release of contractures by single/multiple Z-plasty techniques in cases presenting as linear contracture band with healthy skin on either side and in web contractures
  • Release of contracture and FTSG for coverage over flexor aspect of digits and palm if the defect was small
  • Release of contracture and SSG if the resultant raw area was large.


Release of contracture by Z-plasty was carried out in thirty cases (30%). This technique was possible in 13 cases (56.52%) of axillary contractures, 6 cases (35.29%) of flexion contracture elbow, 5 cases of first web contracture hand (10.86%), and 6 cases (13.04%) of contracture affecting digits. However, as many as 51% of the cases were managed by release/excision of scar/contracture and soft-tissue cover by SSG. These cases included axillary region 10 cases (43.47%), elbow region 11 cases (64.70%), wrist area 20 cases (100%), and hand 10 cases (21.73%). Contracture release and cover by FTSG were employed in 19 cases (41.30%) where the defect was on working surface of the digits/palm.

Visual analog score for patient satisfaction

Patient satisfaction [Graph 2] was calculated at the end of 1 and 6 months. Patients were enquired about range of movements across affected joints, function, ability to perform routine household chores/ability to perform preinjury function, and cosmetic appearance of the operated part. We found that patient satisfaction was much better (mean 6.83 at the end of 1 month which improved to 8.06 by 6 months) in cases where Z-plasty was carried out. VAS was comparatively low in SSG group (mean 5.33). Group of patients who underwent cover by FTSG had VAS score of 7.15 and P < 0.0001.



Post surgery hospital stay

Average hospital stay [Graph 3] was found to be least for Z-plasty group (9.40 days) whereas patients in FTSG and SSG group had longer stay (14.15 and 15 days, respectively) in the hospital before they could be discharged and P < 0.0001.



Recurrence of deformity

Full correction of deformity was achieved in all the cases on operation table, and subsequent maintenance of this correction was assessed critically during follow-up. Cases where deformity recurred and range of movements at particular joint diminished subsequently were labeled to have developed recurrence. Out of 100 patients evaluated in this study, only 4 patients developed recurrence. There was no recurrence in Z-plasty group. Recurrences were observed in 4 cases managed by release and SSG (P < 0.001) and hence statistically significant.


  Discussion Top


Hand and upper extremity burns are the leading cause of impairment of function following major burns trauma. Loss of hand use may result in impairment up to 95% function of upper extremity and up to 57% loss of function of the body.[4]

Despite advances in the management of acute thermal injuries, contractures still occur, and burn trauma happens to be the most common cause of skin contracture in hand.[5] We present in this series two of the basic reconstructive surgical techniques for managing axillary, antecubital, wrist, digits, and interdigital web contractures with special emphasis on the techniques which can be carried out by a general surgeon as well.

The disability produced by axillary contracture may vary from limitation in abduction at shoulder to full adduction, and the arm may be plastered against the lateral chest wall. Karki et al. studied 44 cases of PBCs involving axillary region and found anterior axillary fold involvement in 8 (18.18%) and postfold involvement in 10 (22.72%) cases.[3] In our study, we found type-1 axillary contracture in 13 (56.52%) of cases and type-3 contracture in 10 (43.47%) cases. Type-1 cases were managed by release by multiple Z-plasty techniques. Hirshowitz and Karev recommended 5-flap Z-plasty technique for such contractures.[6]

In our series, we had 17 cases of elbow contractures, and 16 of them (94%) had contracture on the flexor aspect whereas extensor aspect was involved in only one case (6%). Six of these flexion contractures (35%) presented as semi-lunar shaped linear scar creating a pocket. These were managed by 5-flap Z-plasty technique and rest of the cases (65%) by release and SSG. Balamuka et al. in their study found the involvement of flexor aspect of the elbow in all cases, and 50% of them were managed by release and SSG.[7] Wrist and hand contractures are equally disabling, and deep burns of hands may cause crippling claw hand deformity if burns involve metacarpophalangeal region. There were 20 cases of burns where wrist area was involved and as many as 46 patients had contractures involving hands. We managed all cases of contractures involving wrist area by release/excision of scar and SSG. Gulati et al. in a report of 218 cases of hand contractures applied Joshi External Stabilizing System external fixator after conservative release of contracture to achieve correction of deformity.[8] For the management of burn contracture of hands, the treating surgeon should attempt to restore function of the hand rather than only cosmetic correction. First web contracture is noticed quite frequently in hand burns resulting in limitation of grasp function. We employed the 5-flap Z-plasty technique for correction of this deformity with gratifying results. Contracture involving working surface of digits was managed mainly by excision of contracture scar and FTSG with equally good results. Patients in the group undergoing release of contracture by Z-plasty had the highest satisfaction mean VAS = 6.83 and 8.06 at 1 and 6 months. Patients in the group having undergone contracture release with SSG had the least VAS score of 5.33. However, patient groups which were managed by FTSG had mean VAS of 7.11 (1 month) and 7.15 (6 months). This study was found to be significant as P - 0.0001. This is comparable to study carried out by Iwuagwu et al. who concluded that patients reported better satisfaction with the full-thickness skin grafts (P < 0.048).[9] Olaitan et al. in his study concluded that contractures where release and skin grafting are carried out exhibit the highest recontracture rate. Z-plasty in any form produce good results with minimal complications.[10] Sabet also mentions that the technique of Z-plasty gave better satisfaction as compared to SSG.[11]

Postsurgery, patients were advised to maintain affected joints in corrected position by night splintage and pressure garments. Although it is not conclusively proved, how does the pressure garments help; however, their application hastens the scar maturation and encourage reorientation of collagen fibers into uniform parallel pattern. Pressure garments also protect healed skin grafts and help in preventing recurrence of contractures.[12] In our series, four patients developed recurrence of deformity to some extent. There was no evidence of recurrence in patients managed by Z-plasty. Four patients who developed recurrences of deformity happened to be from group managed by release and SSG. This observation was found to be significant (P < 0.001), and such recurrence may possibly be because of lesser compliance of these patients to night splintage and regular use of pressure garments. Pensler et al. compared full-thickness skin grafts with split-thickness skin grafts for reconstructing the palms of 25 children with follow-up of between 3 and 9 years duration. Their results showed that 1.2 operations per hand were required for the split-thickness skin graft group and 1.3 per hand for the full-thickness group. However, there was no recurrence in Z-plasty group.[13]

Patients who underwent release of contracture by Z-plasty had least duration of stay in hospital (mean 9.40 days) as compared to patients who had undergone release of contracture and SSG (mean 15 days). This is consistent with the study by Bhattacharya who mentions that if the graft take up is good, the splint can be removed by 2–3 weeks.[14]


  Conclusion Top


  • Postburn linear scars fare better than dense scars in terms of esthetics and duration of hospitalization
  • Dense scars on excision leave a large soft-tissue defect and require soft-tissue cover by skin grafting
  • If the contracture is released fully and all fibrous tissues are excised from the wound bed, then skin grafts also provide satisfactory results
  • Excision of contracture scar and cover by FTSG over working surface of digits produces good results
  • PBCs managed only by release, and SSG may show early recurrence because of remaining scar tissue in the wound bed. Poor compliance of patients for regular use of pressure garments in such cases may also contribute to recurrence, which may require further surgery at a later stage.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Goel A, Shrivastava P. Post-burn scars and scar contractures. Indian J Plast Surg 2010;43:63-71.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Stampolidis N, Castana O, Nikiteas N, Vlasis K, Koupidis SA, Grammatikopoulos IA, et al. Quality of life in burn patients in Greece. Ann Burns Fire Disasters 2012;25:192-5.  Back to cited text no. 2
    
3.
Karki D, Mehta N, Narayan RP. Post-burn axillary contracture: A therapeutic challenge! Indian J Plast Surg 2014;47:375-80.  Back to cited text no. 3
    
4.
Saunders RJ, Astifidis RP, Burke SL, Higgins JP, McClinton MA. Hand and Upper Extremity Rehabilitation – A Practical Guide. 4th ed. St. Louis, Missouri: Elsevier; 2016.  Back to cited text no. 4
    
5.
Kurtzman LC, Stern PJ. Upper extremity burn contractures. Hand Clin 1990;6:261-79.  Back to cited text no. 5
    
6.
Hirshowitz B, Karev A, Levy Y. A 5flap procedure for axillary webs leaving the apex intact. JPRAS 1977;1:48-51.  Back to cited text no. 6
    
7.
Balumuka DD, Galiwango GW, Alenyo R. Recurrence of post burn contractures of the elbow and shoulder joints: Experience from a Ugandan hospital. BMC Surg 2015;15:103.  Back to cited text no. 7
    
8.
Gulati S, Joshi BB, Milner SM. Use of Joshi external stabilizing system in postburn contractures of the hand and wrist: A 20-year experience. J Burn Care Rehabil 2004;25:416-20.  Back to cited text no. 8
    
9.
Iwuagwu FC, Wilson D, Bailie F. The use of skin grafts in postburn contracture release: A 10-year review. Plast Reconstr Surg 1999;103:1198-204.  Back to cited text no. 9
    
10.
Olaitan P, Onah I, Uduezue A, Duru N. Surgical options for axillary contractures. Internet J Plast Surg 2006;3:154-8.  Back to cited text no. 10
    
11.
Sabet AM. The treatment severe axillary contractures using of the parascapular flap in conjunction with other reconstruction techniques. Egypt J Surg 2004;2:172-8.  Back to cited text no. 11
    
12.
Procter F. Rehabilitation of the burn patient. Indian J Plast Surg 2010;43 Suppl:S101-13.  Back to cited text no. 12
    
13.
Pensler JM, Steward R, Lewis SR, Herndon DN. Reconstruction of the burned palm: Full-thickness versus split-thickness skin grafts – Long-term follow-up. Plast Reconstr Surg 1988;81:46-9.  Back to cited text no. 13
    
14.
Bhattacharya S. Avoiding unfavorable results in postburn contracture hand. Indian J Plast Surg 2013;46:434-44.  Back to cited text no. 14
[PUBMED]  Medknow Journal  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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