Burn Contractures Research Articles

The Use of Acellular Dermal Matrix in Release of Burn Contracture Scars in the Hand

Contracture deformities of the upper extremity are encountered frequently in burn victims. Surgical repair of this problem is challenged by a paucity of soft tissue, poor functional outcome, and a high rate of recurrence. Acellular dermal matrix has become increasingly popular in reconstructive surgery--at times--as an alternative to local and free tissue transfer in different parts of the body. However, its applicability in contracture release, particularly in hand surgery, has not been widely explored. Nine patients with burn contracture scars involving different locations in the hand and the wrist underwent two-stage reconstruction consisting of contracture release and use of acellular dermal matrix followed by definitive coverage with skin graft at the second stage. Patients were followed up for a period of at least 10 months (range, 10 to 25 months), during which time the passive range of motion of the hand was used as a quantitative measure of surgical outcome. All nine patients retained at least 83 percent of the corrected range of motion involving the affected joints by 1 year and at least 89 percent of correction at each webspace. No patient required a revision procedure. Acellular dermal matrix can be an effective tool in surgical treatment of difficult burn contracture deformity in the hand, with lasting results.

Electrophysiological and histological changes in extrinsic muscles proximal to post burn contractures of hand

Burn scar hand contractures of variable degree are frequently encountered. Although the forearm is apparently spared, it was clinically observed that there was disuse atrophy in the unburnt extrinsic forearm muscles. Usually the clinicians do not give much importance to this fact. The girth at the midforearm was significantly reduced as compared to normal side. The flexion of the hand joints are governed by two components (a) intrinsic and (b) extrinsic muscles. The intrinsic muscles are directly involved in the contracted tissue. Therefore it was thought essential to evaluate the extrinsic group of muscles for their contribution in the final functional recovery following corrective surgery. Thirty patients having unilateral post thermal burn contracture sparing forearm were studied. A detailed clinical evaluation was made including grade of contracture and reduction in the forearm girth. The forearm unburnt muscles were evaluated by preoperative electrophysiological studies. Intraoperative biopsies were taken from these muscles for histopathological examination. On histopathological examination, there were significant abnormal changes in the form of muscle fiber atrophy, fibrolipomatous tissue replacement of atrophic muscle fibers and sarcolemmal changes. These changes were directly proportional to the severity of contractures. The electrophysiological studies showed proportionate changes in the form of reduction in amplitude, duration and interference. This study suggests that if these changes are mild and in reversible stage, they will favourably affect the functional recovery following surgery. However if these changes are of severe grade and irreversible, in spite of adequate surgery, splinting and physiotherapy, the functional recovery may not be complete.

Socioeconomic factors affecting presentation of patients with post burn contractures of the hand in an Indian population– a review of 196 cases

Background: As the etiological factors of burn injuries vary considerably in different communities, careful analysis of the epidemiological features in every community is needed to formulate a sound prevention programme. The present study attempts to analyze the demographic factors affecting the presentation of post burn contractures of hand in a developing country.Material and Methods: The study was conducted prospectively and retrospectively between 2004 and 2009. The patients were analyzed for their demographic profile. The patients and their family were asked to state the reason for seeking treatment and the patient’s narrative was recorded in his or her own language.Result: The age of presentation ranged from three to 65 years. Agricultural workers were the most common affected group of population (32%) followed by students (16%). Sixty four percent of all cases had injury due to flame burns. Electric burns were the second most common group (12%). Job related disability was the most common reason for seeking treatment amongst males (59%). Females most commonly sought treatment because of the inability of the family to find a suitable matrimonial alliance (57%). Forty four of the 102 males had a delay of less than six months in seeking treatment. Overall, 75 of 102 males sought treatment in the first year while only 13 of the 94 females reported for treatment within the first six months.Conclusion: We suggest that preventive community programmes for burn contractures of the hand should be based on sound epidemiological studies and should take into account the socioeconomic requirements of the given society.Key words: Burn contractures, Socio-economic factors, Felt need.

Fasciocutaneous flaps based on a doppler detected perforator, an illustrative series as used for burn contracture reconstruction

Perforator flaps are well established as a versatile option in reconstructive surgery that provide thin, pliable cutaneous or fasciocutaneous tissue. They are particularly useful in the reconstruction of large shallow defects, such as after the release of a burn contracture, however there are situations where the additional time spent islanding these flaps may be unnecessary, and the flap is then essentially a fasciocutaneous flap based, but not islanded, on a perforator artery. This paper documents a series of 22 severe burn contractures in 17 patients reconstructed with fasciocutaneous flaps in this way. The arteries were all located pre-operatively with a hand held Doppler probe, around half at the site of a known perforator and half by systematic scanning of the surrounding skin for an ad hoc perforator. All patients achieved a good functional range of motion. There were three cases of partial superficial flap necrosis treated with split skin grafting. The functional and aesthetic outcomes were far better then those expected with split skin grafting, and published series show that contractures treated with perforator flaps are unlikely to ever need further surgery. Without islanding the flap it becomes a feasible option for reconstructing these patients even in the extremely resource poor environment in which they often present, and is an option for all plastic surgeons to consider in the reconstruction of large superficial defects.

Reconstruction of severe hand contractures: An illustrative series

Aim:An overview of a series of severe burn contractures in 44 hands reconstructed over a 20 month period with an easy to follow algorithm.Settings and Design:The series was carried out by a single surgeon at Green Pastures Rehabilitation Centre in Pokhara, Nepal. All patients attending with severe burn contractures to the hand were included in the series.Materials and Methods:This is a retrospective review of burn contractures in a total of 44 hands. All the contractures involved limitation of movement by 60 degrees in two or more joints or by 80 degrees in one joint. The decision making process is presented as a flow chart indicating when and which flaps were used.Results:Illustrations demonstrate what was achieved, with all hands obtaining an improvement in function.Conclusions:Although many of these contractures can be dealt with by skin grafting the series clearly illustrates the indications for flap coverage.

Establishing a children’s orthopaedic hospital for Malawi: An assessment after 5 years

Beit Cure International Hospital (BCIH) is a specialist orthopaedic hospital providing surgical services to the children of Malawi. The hospital started treating patients in late 2002, and this analysis represents an attempt to assess the impact of the hospital, and develop strategies for future partnerships and development. Analysis was made of all the 563 case files of new patients treated operatively in the fifth year of hospital services. Data recorded included district and region of origin of patient, diagnosis, age and sex. Patients were treated from all 3 regions, with almost 50% coming from Southern region. Club foot, burn contracture, and genu varus were the most common diagnoses. Half the children were infants up to 5 years of age, while 60% were male. The underlying reasons behind these findings are analysed and their implications in terms of future hospital strategy are discussed.

Pre‐expanded pedicled thoracodorsal artery perforator flap for postburn axillary contracture reconstruction

The axillary region is one of the sites most frequently affected by postburn contractures. In this clinical study, we used pre-expanded pedicled thoracodorsal artery (TDA) perforator flaps for release of postburn contracture of the axillary region. Five patients with severe axillary burn contractures were reconstructed with six pre-expanded pedicled TDA perforator flaps between 2008 and 2010. All were men ranging in age from 20 to 26 years (mean, 22 years). Mean time of follow-up was 12 months. Flap and donor site complications, preoperative, and postoperative range of motion of axillary joint were evaluated. All flaps survived without significant complications. Partial flap necrosis was seen in only one flap. Minimal transient venous congestion occurred in one flap during the early postoperative period. A complete range of motion at the axillary joint was achieved in all patients by the end of the reconstruction period. The donor sites were closed primarily with linear scars in all cases. The pre-expanded pedicled TDA perforator flap is a suitable alternative for coverage of the axillary defects after the release of the burn contractures. A pliable texture and large size flap can be obtained to transfer to the axillary area and the donor site scar is considered as cosmetically acceptable.

Use of the lateral intercostal artery perforator-based pedicled reverse thoraco-abdominal flap for treatment of antecubital burn contractures

We describe a lateral intercostal artery perforator-based pedicled reverse thoraco-abdominal flap for coverage of the antecubital fossa after burn scar release. In this study we describe raising and insetting the flap and reported our clinical results and observations. Antecubital contracture release was carried out in six patients, and the lateral intercostal artery perforator-based pedicled reverse thoraco-abdominal flap was raised based on the anterolateral cutaneous perforator of the appropriate intercostal artery. The defects were repaired with this flap. All the flaps survived and antecubital contractures were repaired successfully. No recurrent contracture occurred in any of the patients at a mean of 15.3 months. The lateral intercostal artery perforator-based pedicled reverse thoraco-abdominal flap can be used effectively for repair of antecubital tissue defects as an alternative to other reconstructive methods.

Epidemiology of Surgical Admissions to a Children’s Disability Hospital in Nepal

The goal of this retrospective review was to characterize the spectrum of surgical admissions to a tertiary hospital specializing in musculoskeletal conditions in children and adolescents in Nepal. We reviewed hospital records from 1996 to 2006 to categorize all major surgical procedures. Additional information collected included diagnosis, patient age, gender, and home district. Of 7,556 major surgical procedures performed from 1996 to 2006, 91% could be placed within the following categories: congenital (n = 2,984; 38%), burn contracture (n = 1,400; 19%), posttraumatic (n = 1,047; 14%), neuromuscular (n = 750; 10%), and infection (n = 731; 10%). The most common diagnosis was congenital clubfoot, which accounted for 2,348 cases (31%). Thirty-three percent of cases (n = 2,447) involved injuries (burns, fractures, dislocations). While burns most commonly involved the upper extremity, fractures in the elbow region were the most frequent posttraumatic problem. The most common neuromuscular diagnosis was poliomyelitis. The sequelae of musculoskeletal sepsis represented 731 cases (10%), most commonly chronic osteomyelitis. Other diagnoses termed miscellaneous included angular deformities of the lower extremities, scoliosis and other spinal deformities, hip dysplasia, and tumors. The majority of surgical pathology involved injuries and congenital problems (mainly clubfoot). The presentation was delayed in most patients, and in such cases, the treatment is more complex and costly, and the desired functional outcome is difficult to achieve. In addition to preventive measures, morbidity cases could have been reduced by the timely provision of services at the primary referral level. Strengthening the delivery of basic orthopedic services at primary health care facilities may eliminate or reduce the need for complex reconstructive procedures and diminish the likelihood of permanent disability in our population.

Tumescent anaesthesia for post burn contracture release

Tumescent anaesthesia for post burn contracture release

Post burn contracture neck with extreme microstomia and fibrosed obliterated nose - A unique airway challenge!

Post burn contracture neck with extreme microstomia and fibrosed obliterated nose - A unique airway challenge!

Infected epidermal inclusion cyst mimicking Marjolins ulcer in a case of Post Burn Contracture axilla

Background: We describe here a very rare presentation of Post Burn Contracture axilla in which an underlying infected epidermal inclusion cyst was mimicking Marjolin’s ulcer in its presentation.Material and Methods: The patient with Post Burn contracture axilla was treated with release and split skin grafting after excision of the epidermal inclusion cyst.Results: Axilla was released and grafted. Patient was kept on strict splintage and physiotherapy programme to encourage movements. The patient is on regular follow-up and further monitored physiotherapy has been planned to provide a better functional and aesthetic limb.Conclusion: The presentation of Post Burn Contracture axilla described here has not been mentioned in world literature so far and its presentation is a matter of discussion. Opinions regarding possibilities of such presentation are invited from experts in the field.

Commentary on “Plastic surgery and global health: How plastic surgery impacts the global burden of surgical disease”

It is enormously encouraging to have this publication in the Journal to draw much needed attention to the role of reconstructive plastic surgery in managing the global burden of surgically correctable disease. At the outset of a short commentary, my sole reservation relates to the need for such a message to be broadcast as widely as possible in global medical literature, where it might be acknowledged and acted upon by those outside our discipline who have influence in world health policy direction. I hope that this important message reaches a wider audience in due course, possibly in a general medical publication. As well as surveying the broad areas of morbidity and disease that plastic surgery can address, the paper makes a valuable start at quantifying the extent of such disabling conditions. It also describes the level of medical workforce support which is currently marshalled to address the problem. There are a couple of matters which I suspect might have augmented the authors argument yet further. Firstly, whilst the limitations of the DALY in quantifying the long-term life impact of conditions such as chronic burn contracture, or Clefting are described, there is no attempt to direct future efforts to improve such estimations. I would suggest that one of the most urgent requirements in developing world surgically related research should be a twin pronged attack to a) develop much more accurate data on the incidence

Pattern and outcome of children admitted for burns in Benin City, mid-western Nigeria

ABSTRACTChildren are a vulnerable to burns, an injury, which is often preventable. A study of the profile of cases of children admitted for burns will provide background information to suggest locally doable preventive strategies as well as supply basic information for future reference. We studied the records of 62 children aged 0-16 years, admitted for burns, at the University of Benin Teaching Hospital, Benin City, between January 2002 and December 2006. There were 34 male and 28 female children. Children under three years constituted 56.5%. Whereas the leading cause of burns in all the children was flame burns from kerosene explosions (52%), scalds were responsible for 68.6% of cases in those under three. The extent of burn injury ranged from 6 to 50% and most of them presented late. 64.6% were discharged within three weeks. Wound sepsis and post burn contractures were the most frequently encountered complications (19.4% and 9.7% respectively). There were two deaths (3.2%) related to sepsis. Particular attention to burn safety precautions in children (especially, in the >3 years age group), safer storage and dispensing of combustible chemicals particularly petroleum products is advocated. Fire safety awareness, correct first aid measures and early presentation in the hospital will reduce morbidity and mortality. Early physiotherapy and splinting strategies will reduce contractures. There is the need locally for the establishment of specialized burn centres both to treat these children and to stimulate interest in burn management.

Distally Based Venous Flap for Proximal Phalangeal Soft Tissue Burn Defect and Web Space Burn Contracture

Flap choices for the coverage of the proximal phalangeal soft tissue defects of the finger and web space burn contractures are limited. A unipedicled distally based venous flap was raised from the third or fourth metacarpal area of the hand for proximal phalangeal soft tissue defects of the finger and web space burn contracture. For clinical use, we operated seven male patients using this venous flap. Superficial necrosis involving two flaps did not interfere with flap survival. Mild edema and venous congestion occurred in all flaps. All flaps survived completely. The mean follow-up period of the flaps was 6 months, ranging from 3 to 14 months. A well-planned distally based venous flap is an useful option for the coverage of the proximal phalangeal soft tissue burn defects of the finger and web space burn contracture of the hand.

Pentoxifylline modifies three-dimensional collagen lattice model contraction and expression of collagen types I and III by human fibroblasts derived from post-burn hypertrophic scars and from normal skin

Fibroblasts are thought to be partially responsible for the persisting contractile forces that result in burn contractures. Using a monolayer cell culture and fibroblast populated collagen lattice (FPCL) three-dimensional model we subjected hypertrophic scar and non-cicatricial fibroblasts to the antifibrogenic agent pentoxifylline (PTF – 1 mg/mL) in order to reduce proliferation, collagen types I and III synthesis and model contraction. Fibroblasts were isolated from post-burn hypertrophic scars (HSHF) and non-scarred skin (NHF). Cells were grown in monolayers or incorporated into FPCL's and exposed to PTF. In monolayer, cell number proliferation was reduced (46.35% in HSHF group and 37.73% in NHF group, p < 0.0001). PTF selectively inhibited collagen III synthesis in the HSHF group while inhibition was more evident to type I collagen synthesis in the NHF group. PTF also reduced contraction in both (HSHF and NHF) FPCL.

Multiplanar supramalleolar osteotomy in the management of complex rigid foot deformities in children

Residual midfoot and hindfoot deformities in rigidly deformed feet present a very complicated surgical dilemma. A plantigrade foot is desirous for proper lower extremity mechanics in a child with ambulatory potential. In this group of patients, soft tissue procedures are no longer an appropriate option, and well-recognized hindfoot procedures, such as talectomy, have many disadvantages. This study reviews the results obtained using multiplanar supramalleolar osteotomy as a salvage procedure to correct deformities of the complex rigid foot in children. A retrospective review was conducted of 27 multiplanar supramalleolar osteotomies in 18 children. The underlying diagnosis of the patients included seven severely rigid idiopathic clubfeet, five arthrogryposis, two myelodysplasia, one Ellis-van Creveld, one Streeter's, one cerebral palsy, and one severe burn contracture. The average age at surgery was 5.6 years, and follow-up averaged 8 years. A successful outcome was deemed a plantigrade foot on physical exam with follow-up of at least 2 years and no subsequent tibial surgeries. All failures were included regardless of the length of follow-up. A plantigrade attitude of the hindfoot was obtainable at the time of surgery in all cases. Eighteen of the 27 feet had a successful outcome. Nine of 27 (33%) feet had recurrence of the foot deformity requiring additional surgery. Time to recurrence averaged 5.7 years (9 months-13 years). Complications from the surgery included four minor wound healing problems, two delayed unions, and one screw recession, all of which healed without consequences. There was no evidence of nonunion, growth plate closure, infection, or fracture above or through screw holes. The multiplanar supramalleolar osteotomy appears to be a reasonable salvage procedure for severely scarred and complex rigid foot deformities and can be reinstituted for failures due to remaining growth.

Pattern and outcome of children admitted for burns in Benin City, mid-western Nigeria

Children are a vulnerable to burns, an injury, which is often preventable. A study of the profile of cases of children admitted for burns will provide background information to suggest locally doable preventive strategies as well as supply basic information for future reference. We studied the records of 62 children aged 0-16 years, admitted for burns, at the University of Benin Teaching Hospital, Benin City, between January 2002 and December 2006. There were 34 male and 28 female children. Children under three years constituted 56.5%. Whereas the leading cause of burns in all the children was flame burns from kerosene explosions (52%), scalds were responsible for 68.6% of cases in those under three. The extent of burn injury ranged from 6 to 50% and most of them presented late. 64.6% were discharged within three weeks. Wound sepsis and post burn contractures were the most frequently encountered complications (19.4% and 9.7% respectively). There were two deaths (3.2%) related to sepsis. Particular attention to burn safety precautions in children (especially, in the >3 years age group), safer storage and dispensing of combustible chemicals particularly petroleum products is advocated. Fire safety awareness, correct first aid measures and early presentation in the hospital will reduce morbidity and mortality. Early physiotherapy and splinting strategies will reduce contractures. There is the need locally for the establishment of specialized burn centres both to treat these children and to stimulate interest in burn management.

Reconstruction of the first web space in severely burned hand by the reverse posterior interosseous flap

First web space widening is crucial in the reconstruction of severe thermal burn contracture of the hand. A thin, pliable flap with a long vascular pedicle is required. We describe our experience with the reversed posterior interosseous artery flap in nine patients over a 5-year period for this surgical indication. All flaps survived and we were able to achieve good functional and cosmetic outcomes with minimal donor morbidity. We believe that the reversed posterior interosseous flap is the excellent option for the first web space reconstruction.

Reverse thenar perforator flap for volar hand reconstruction

The glabrous skin of the palm provides the best colour and texture match for reconstructing volar hand defects, but only a limited number of local axial pattern flaps of the palm have been described in the literature. This report describes a new reverse thenar perforator flap harvested from the midpalm and the thenar region. A total of 12 patients with volar hand defects of the index finger, palm, or first web space were reconstructed with this flap between August 2005 and August 2007. The causes of the defects were trauma (one patient), burn contracture release of the first web and index finger (four patients), and Dupuytren contracture release (seven patients). The flap was supplied from one or two of the perforating branches of the terminal branch of the superficial palmar arch or the superficial palmar branch of the radial artery. Flap sizes ranged from 1.5 x 3.0 cm to 2.5 x 6.5 cm. The donor sites were repaired primarily in all patients. There were no major postoperative problems: 11 flaps out of 12 survived completely with just one partial loss. Excellent functional and cosmetic results were observed during a mean follow up of 12.6 months. The reverse thenar perforator flap offers glabrous skin for defects of the palm, first web and index finger. Donor scarring of the flap is minimal and it is suitable for the 'replacement with similar tissue' concept.