Indian Journal of Burns

ORIGINAL ARTICLE
Year
: 2018  |  Volume : 26  |  Issue : 1  |  Page : 9--14

Reconstruction of postburn crippled hands: A study of functional outcome


Narayanan Chandramouli Hariharan1, Rajagopal Sridhar1, B Sankari1, VS Valarmathy2, Ebanesar Asirvatham2, Krishnamurthy Geetha2,  
1 Department of Plastic Surgery, Institute of Non Communicable Diseases and Government Royapettah Hospital, Chennai, Tamil Nadu, India
2 Department of Hand and Reconstructive Micro Surgery, Tamil Nadu Government Multi Super Speciality Hospital, Chennai, Tamil Nadu, India

Correspondence Address:
Prof. Narayanan Chandramouli Hariharan
V-1, Sri Mahalakshmi Enclave, 24, Gandhi Road, Gill Nagar, Chennai - 600 094, Tamil Nadu
India

Abstract

Introduction: In postburn survivors, quality of life depends on the functional ability of one's hands. However, restoring useful function in crippled hands is a formidable challenge. Understandably in such cases, there are no standardized rules regarding the sequence of release, the type of skin cover, the duration of immobilization by K wires, and the intensity of hand therapy. Patients and Methods: We formulated a protocol and evaluated the outcome for cases of severe contractures with a total loss of hand function and distorted hand architecture. It is a cross-sectional study of 10 consecutive patients and 14 hands operated in our department from January 2014 to June 2017. The patients were operated in two stages. At the first stage, contractures of the wrist, dorsum, and thumb web space were released. Extension contractures of the fingers and thumb were also released. During the second stage, the contractures of the palm, volar aspect of the fingers, and web spaces were released. In both the stages, the fingers were maintained in released position for 3 weeks by K wires and the raw areas were covered with split skin graft/skin flap. Results: Patients were assessed for the improvement of hand function by the disabilities of the arm, shoulder and hand (DASH) scores of the 10 patients operated, four returned to the original employment/school. Four found meaningful employment. Conclusion: The aim in crippled hands is to restore useful function in the least number of stages rather than improving the range of movement in individual joints. Maintaining the release achieved by surgery with K wires, coupled with aggressive therapy, prevent the recurrence of the contractures.



How to cite this article:
Hariharan NC, Sridhar R, Sankari B, Valarmathy V S, Asirvatham E, Geetha K. Reconstruction of postburn crippled hands: A study of functional outcome.Indian J Burns 2018;26:9-14


How to cite this URL:
Hariharan NC, Sridhar R, Sankari B, Valarmathy V S, Asirvatham E, Geetha K. Reconstruction of postburn crippled hands: A study of functional outcome. Indian J Burns [serial online] 2018 [cited 2019 Sep 18 ];26:9-14
Available from: http://www.ijburns.com/text.asp?2018/26/1/9/253847


Full Text



 Introduction



Despite advances in burn care resulting in improved survival, the sequelae of deep burns such as hypertrophic scars and contractures remain as significant clinical problems in reconstructive surgery. Of all the major burn injuries, upper extremities are involved in 80%–90% of cases.[1],[2]

In the increasingly cost-conscious society, the expected “quality of life” has become a major criterion for decision-making regarding burn resuscitation. Returning to meaningful employment, the major determinant of quality of life in burn survivors largely depends on the functional ability of one's hands. Total loss of hand function amounts to 57% loss of whole body function.[3]

In many cases, as the extent of burns is life-threatening, active management of the hand burns is delayed leading to unacceptable contractures.

It is a well-appreciated fact that proper splinting and hand therapy prevent the development of contractures. However in practice, the need for frequent dressing changes and the pain associated with the therapy make the patients less compliant. Thus, the patients tend to keep the hands in the position of ease resulting in flexion contractures of the wrist, hyperextension contractures of the metacarpophalangeal (MP) joints and flexion contractures of the IP joints. Secondary healing of the deep dermal burns further complicates these contractures.

McCauley proposed a classification for postburn deformities of the hand.[4] A study of outcomes after full-thickness hand burns stated that if the deep burns involve the dorsum of the hand, despite appropriate corrective surgeries the patients reported “most difficulty” in performing Michigan hand questionnaire activities of daily living.[5] Thus, in severe contractures of both the dorsal and palmar aspects of the hand with total loss of hand function and distorted hand architecture, (McCauley Grade IV C) achieving useful function is a formidable challenge.

For the management of complex postburn contractures of the hand, surgeons vary in their approaches, and understandably, there are no standardized rules regarding the sequence of release, the type of skin cover, and the duration of immobilization by K wires. Hence, we formulated a protocol for the treatment of Grade IV C contractures and evaluated the outcome in this study.

 Patients and Methods



It is a cross-sectional study of 10 consecutive patients and 14 hands of Grade IV C contractures operated in our department from January 2014 to June 2017 [Table 1]. Contractures due to electrical burns and causes such as infection, trauma, and ischemia were excluded from the study. Less severe contractures of Grade I, II, III, IV A, and IV B were also excluded.{Table 1}

Of the ten patients, seven were male and three were female. Age group was 8–46 years. In nine hands, there were associated contractures of the elbow and in four hands, there were contractures of the axilla. Nine patients had sustained major burns (total burn surface area 25% or more). The duration of the contracture ranged from 6 months to 2 years. All these cases underwent at least one surgical procedure for the correction of upper limb contractures involving the axilla, the elbow, the wrist or the thumb web, elsewhere.

Twelve hands were operated in two stages. At first stage, contractures of the wrist, dorsum, and thumb web space were released. Extension contractures of the fingers and thumb were also released, and the MP joints were immobilized in maximum possible flexion by K wires. K wires were passed from the proximal phalanx to the metacarpal bone, volar to the MP joints. The resultant raw areas were covered with split skin graft (SSG) [Figure 1]a, [Figure 1]b, [Figure 1]c. If a tendon or bone was exposed the defect was covered with skin flap. Groin flap was preferred over the reverse flow radial forearm or posterior interosseous artery flaps as we did not want to further compromise the vascularity of the hand.{Figure 1}

K wires were removed after 3 weeks. Patients were then given intensive physiotherapy for 3 weeks. The therapy consisted of active mobilization and passive stretching of the wrist joint, the carpometacarpal (CMC) joint and the MP joints of the thumb and the MP joints of the fingers to the fullest possible range. Deep massage of the scar and the settled skin graft was also administered simultaneously. The patients were instructed to wear the wrist splint, the thumb web spacer, and the knuckle bender splint. After 3 weeks of physiotherapy, they were advised to adhere to the therapy regimen and to wear the splints at rest. Once the active range of movements of the wrist, the CMC joint of the thumb and the MP joints of the fingers could be maintained, and the skin graft got settled well, they were taken for second-stage surgery [Figure 1]d and [Figure 1]e. This was possible 3 months after the first surgery.

During the second stage, the contractures of the palm, the volar aspect of the fingers and the web spaces were released. Fingers were maintained in extension of interphalangeal (IP) joints by 1-mm K wires. The raw areas were covered with SSG/skin flap. If the vascularity of the fingers appeared doubtful at the end of the procedure, the K wires were immediately removed. Otherwise, the K wires were removed after 3 weeks and the hand therapy was started. The patients were instructed to wear the extension splints for the fingers, at rest. After 3 weeks of therapy, patients were allowed to use the hand. However, splinting at rest was continued for 3 months [Figure 2]a, [Figure 2]b [Figure 2]c, [Figure 2]d, [Figure 2]e.{Figure 2}

In one patient with bilateral hand contracture, each hand was operated in four stages as multiple flaps were needed [Figure 3]a, [Figure 3]b, [Figure 3]c, [Figure 3]d, [Figure 3]e.{Figure 3}

In six hands, after contracture release, only SSG was used. In eight cases, skin flap was used in addition to SSG [Figure 4]a, [Figure 4]b, [Figure 4]d, [Figure 4]e.{Figure 4}

Patients were assessed for the improvement of hand function by the disabilities of arm, shoulder, and hand scores (DASH). Patients were encouraged to attend school/go for employment, and further ancillary procedures like IP joint arthrodesis were done if they were likely to improve the hand function significantly. Once the patients were allowed to go for employment, they were followed up for a minimum of 6 months to a maximum of 2 years to assess the hand function and to detect the recurrence of the contractures.

 Results



Of the 10 patients operated, two returned to their schools to continue their studies [Figure 5]a, [Figure 5]b, [Figure 5]c, [Figure 5]d, [Figure 5]e. Two returned to the same employment. Four patients found meaningful employment [Figure 6]a, [Figure 6]b, [Figure 6]c, [Figure 6]d, [Figure 6]e. Two patients were not confident to go for employment. In bilateral hand contractures, the mean preoperative DASH score was 95.6, and the mean postoperative score after correction of both the hands was 28.5. In unilateral contractures of the dominant hand, the mean preoperative DASH score was 65 and the postoperative DASH was 22.5. In the two nondominant hand contractures that were operated, the mean preoperative DASH was 47.9. The child who was operated for the nondominant hand contracture reported no disability after the corrective surgeries (DASH 1.7) [Figure 7]a, [Figure 7]b, [Figure 7]c, [Figure 7]d. In the other patient, the postoperative DASH was 12.5.{Figure 5}{Figure 6}{Figure 7}

Of the 14 hands that were operated, in five hands, the skin defects were covered only with SSG. In six hands groin flap was used to cover the skin defects. In two hands, abdominal flap was used to cover the skin defect. In one hand, reverse flow radial forearm flap was used in addition to the abdominal flap. In 12 hands, the release obtained at the time of surgery was maintained. In two hands, there was significant relapse necessitating revision surgery.

There was no case of flap loss. There was no significant K wire related track infection. Ancillary procedures like proximal IP (PIP) arthrodesis, was done in two cases. In two cases, k wires were removed postoperatively due to precarious vascularity of the fingers. Although the loss of digits due to intraoperative ischemia is a feared possibility, we did not encounter this complication in our series.

 Discussion



The foremost problem in crippling postburn contractures is the inability to achieve the full release of the joints of the digits. The contracted joint capsule and the ligaments resist adequate release of the contractures. Aggressive capsulotomy may help in achieving full release at the cost of joint stability. However, the stability of a joint is as important as mobility in restoring useful hand function. Graham et al. reported that in type III deformities of the MP joints where passive flexion beyond 30° of hyperextension was not possible, only 47% had a satisfactory surgical outcome.[6] Stern et al. classified the flexion contractures of the proximal IP joints and concluded that surgical outcome is poor in type III contractures where there is capsular shortening with narrowing of the joint space.[7] Flexion contractures of the distal IP joints associated with deep dorsal burns often result in destruction of the articular surfaces, and hence, arthrodesis is the only option.[8] Amputations of the fingers might be an option in severe multiple joints contractures, especially if the digits are painful.[8]

We could obtain acceptable correction by the minimal release of the contracted collateral ligaments coupled with slow and steady stretching of the joints. However, the joints were pulled back to the original contracted position due to the elasticity of the contracted capsule. Hence, we immobilized the joints after release by K wires. Contracted volar plates and ligaments tend to pull the joints to the original deformed position, and the weak power of the long unused muscles are never sufficient to overcome this.[9] Further, the shortened muscles should be kept stretched at the maximum possible limit as the tendon excursion, and the resultant range of motion depends entirely on the length of the muscle fibers.[10]

Although McCauley [4] showed that children tolerate 4–6 weeks of immobilization, the optimal period of immobilization in adults is debatable for fear of joint stiffness. Hence, we formulated a protocol of immobilization of the hand in the corrected position for 3 weeks by K wires to negate the elastic recoil of the contracted ligaments.[11]

Skin grafts became stable in 3 weeks, and the release could be maintained with splints after 3 weeks. As K wires through the MP joint can cause varying degrees of joint destruction, we passed the wire from the proximal phalanx to the metacarpal neck, volar to the MP joint. To keep the IP joints in an extension, we passed 1-mm K wire through the terminal phalanx, DIP joint, middle phalanx, PIP joint and the proximal phalanx taking care to keep the MP joints free. Hence, the patients could continue MP mobilization with the K wires in place. If the K wires are passed through the soft tissues of the fingers, mobilization of the MP joints will not be possible as the K wires tend to migrate and cause pain.

The secondary contracture of the SSG is often blamed for the recurrence of the contracture. But the flaps also do not offer foolproof solution to prevent the recurrence of the contracture. The recoiling tendency of the released joints is primarily responsible for the recurrence. Although active mobilization can be initiated, the muscles require sustained therapy to regain the strength to achieve a full range of movements. Till then, splinting is to be continued. Hence, we did not resort to preferential use of skin flaps. We used the skin flaps only if the bed was not likely to accept the SSG.

Ideal sequence of contracture release of the upper limb is another debatable issue. It is often said that the release should go from proximal to distal. On the other hand, contractures of the small hand joints are to be corrected at the earliest to obtain optimum results. If contractures of the axilla or the elbow are not significant, correction of the hand contractures should be given priority. Moreover, the position of the shoulder or the elbow has no bearing on the correction of the hand contractures.

However, the wrist is to be corrected before the release of finger contractures, as the wrist position greatly affects the finger movements. Due to the checkrein effects of the long flexors and the extensors of the fingers, extreme positions of the wrist and the MP joints are to be corrected to obtain full release of the fingers.

With the wrist in extreme flexion, the full release of the thumb web space and complete correction of the hyperextension deformity of the fingers is not possible. With the wrist in extreme extension, total correction of the flexion contractures of the fingers is difficult. If MP joints are kept hyperextended, full release of the flexion contractures of the IP joints is not possible.

Hence, we corrected the wrist, thumb web, dorsum of the hand, and the hyperextended MP joints in stage I. Hand was immobilized in the first position, so that maximum possible area on the dorsum of the hand and fingers could be covered with SSG.

Release of the palm, flexion contractures of the thumb and the fingers were corrected in the second stage. In severely contracted palm, we excised the palmar aponeurosis to open up the palm.

In these cases, selecting an ideal flap [12] is a problem as there were burns related scarring of the forearms and the abdomen. We preferred the groin flap as: (1) The flap is relatively thin compared to abdominal flaps. (2) The donor defect can be closed primarily. (3) The procedure does not compromise the blood flow to the hand. Furthermore, in most cases, the groin was not involved by the burn injury.

We avoided reverse flow forearm flaps like radial forearm flap or posterior interosseous artery flaps, as we did not want to reduce the blood supply to the hand in any way. Free flaps [13],[14] were also not used as that would involve sacrificing a part of the blood supply to the rest of the hand. Masuoka et al. transferred a free scapular flap to the inguinal region and used it as a pedicled flap to resurface the defect in the hand, after the release of burn contracture.[15] They contended that survival of free flap was unpredictable in their patient due to repeated arterial punctures during intensive care monitoring of the patient and paucity of superficial veins owing to deep forearm burns. These problems exist in most cases of severe hand contractures.

After complete release in severe contractures, the vascularity of the fingers is often precarious, and only a good perfusion pressure in hand can ensure the viability of the fingers. However, in a case of bilateral hand contracture, we used reverse radial forearm flap for proximal palm and thumb web as the patient could not arrange for an attendant to take care of him for 3 weeks.

After K wire removal we admitted the patients for 3 weeks of hand therapy, as irregular therapy in this phase jeopardize the results.

We did not use full-thickness grafts since the requirement of skin was large, and there was a paucity of unscarred skin. Further, studies documented that there was no significant difference between the use of full-thickness skin grafts and SSGs in preventing the recurrence of the contracture.[16] Nevertheless, the secondary contracture of the SSGs could be effectively minimized by k wire fixation and splinting.

Admittedly, there is no benchmark to rate the disability based on DASH scores. A study by Gummesson et al. proposed that a 10 point difference in the DASH score may be considered as a minimal important change.[17] The mean improvement in the DASH scores observed in this study ranged from 35.4 for contracture of the nondominant hand to 67.1 for bilateral contractures, denoting significant improvement.

Although the number of cases in this series is not large, even in relatively large series the number of patients treated for Grade IV C contractures is far less or not specified.

 Conclusion



The aim in postburn crippled hands is to restore useful function in the least number of stages rather than improving the range of movement in individual joints. Maintaining the release achieved by surgery with K wires, coupled with aggressive therapy prevent the recurrence of the contractures. Thereby, successful rehabilitation is possible for motivated patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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