Burn Scar Contracture Research Articles

T1 Measuring Burn Scar Contracture: Challenging the Standard

Standard goniometry is the most commonly used method of assessing range of motion (ROM) in patients with burn scar contracture. However, standard goniometry disregards the cutaneous biomechanical influence between adjacent joint positions and skin (or scar) pliability to accommodate motion. Given that natural skin is a single, continuous piece of tissue enveloping the entire body without joints, the appropriateness of standard goniometry to quantify motion when burn scars or other integumentary impairments are the source of limitation, is called into question. We conducted a prospective, multi-center, comparative study investigating the difference between two goniometric protocols for measuring ROM outcome in burn survivors: 1) standard goniometry - based on arthrokinematics and 2) revised goniometry - based on principles of cutaneokinematics and functional positions. Maximal active ROM was measured for 11 motions, three times in each position in random order. Data were summarized using means and standard deviations and analyzed using a mixed model ANOVA with each subject representing a random effect in the model. Pearson’s Correlations were performed between the severity of limitation and the percentage of scar involvement. Data were collected for 174 joints from 66 subjects at seven different burn centers, resulting in a total of 1044 goniometric measurements for comparison. ROM findings using the revised goniometric protocol demonstrated significantly more limitation in motion 38.8 %±15.2% than the standard goniometric protocol 32.1% ±13.4% (p<.0001). Individual analyses of the motions likewise, showed significantly more limitation with the revised methods compared to the standard methods for 9/11 motions. Pearson’s correlation showed a significant positive correlation between the percentage of area affected by scarring and ROM outcome with revised goniometry (R2=.05, p=.0008) and the Δ between the revised and standard protocols (R2=.04, p=.0025) but no correlation was found with standard goniometry (R2=.015, p=.065). These findings support the notion that standard goniometry underestimates the ROM impairment for individuals whose motion is limited by burn scars. Due to the high frequency of movement related problems that burn survivors experience, ROM is a foundational outcome measure. It is used as a marker of recovery, influences function, affects quality of life and contributes to the decision of resource allocation during recovery. Therefore, having measurement methods that consider the unique characteristics of skin impairment is an important priority for both clinical reporting and future research in burn care. Clinical change in fundamental methods of measuring ROM after burn injury.

The scourge of burn contractures: Who will bell the cat?

IntroductionMajority of burn injuries occur in developing world. There have been many advances in burn care management. But this advance comes at a price of ever increasing burn sequel of scarring. Burn scar contractures, in spite of being preventable, continue to be a common reality in our world. This paper aims to evaluate the lacunae in burn care leading to formation of contractures, to evaluate common sites of contractures, practice of advising splintage and anti-deformity positioning. ProcedureThis retrospective observational study was conducted over a period of six years (January 2010–December 2015) at a tertiary Burn unit in Mumbai (India). The records of burn contracture patients were scrutinized to obtain the data regarding patient’s socio-demographic profile, details of burn injury, splinting and exercises advised and details of surgeries required. Data was tabulated and analysed. ResultsThere was a significantly lower prevalence of advice regarding splinting, mobilization exercises and pressure garments. The prevalence of early surgery was also found to be low. ConclusionsAttempt has been made to identify the factors affecting the prevalence of burn scar contractures. Authors recommend that efforts be made for improving the knowledge of the treating doctors. Also, efforts should be made to increase awareness of burn prevention and emergent management.

Double V-Y Flaps for Post Burn Contracted Neck

Background: Several techniques have been defined to beused in surgical treatment of post burn contracted neck. But,there were many problems with those techniques, like failureof graft take and postoperative contracture of the graft. Thecommonest problem in those techniques was distal flap necrosiswhich is frequently seen. As most of these techniques werebased on random-pattern flaps and there is usually a poorblood supply to the scar tissue. But, here in this study, we canbenefit from expansion in the distal part of the upper chestand lower neck caused by continuous traction of the contractedband which leads to expansion of the surrounding tissue withexcess skin.Aim of the Study: In this study, we aim to shift the excesstissue resulted from tissue expansion caused by traction ofthe contracture band from the base of the neck and upperchest to the upper neck by “double V-Y flaps” with directclosure of the donor site.Patients and Methods: 17 patients with post burn scarringof the neck were included in this study. 11 females and 6males with average age 20 (9-32) years old. 9 patients withdouble linear contracture and 8 patients with band contracture.Release of post burn scarring of the neck by “double V-Yflaps” was done, the excess tissue of the flap was used anddirect closure of the donor site was done.Results: The postoperative results represent the successof this technique in the surgical treatment of post burn scarcontractures of the neck. All patients had an uneventfulpostoperative period with no distal flap necrosis. There waspostoperative wound disruption in one patient that was managedby secondary sutures. The post burn scarring was successfullymanaged with this surgical technique “double V-Yflaps”, with no major postoperative complications. One yearfollow-up period revealed no recurrence of the contractedbands.Conclusion: “Double V-Y flaps” is a good technique insurgical treatment of post burn contracted neck with doublelinear or band contracture lines. This technique offers thepatient a good chance for release of post burn contracted neckwith no need to use graft or to wear postoperative neck collar.

Correction of Cord Like Scars Using Running Opposing Y-V Plasty

Linear scars are a common problem in the plastic surgerypractice. Release is the first step in surgical treatment. Skingrafts, Z-plasty, local, regional or free flaps are used tolengthen the scar. In this article, we will use running y-v flapsfor scar lengthening. From January 2016 to April 2017, 20linear burn contractures of 15 patients were corrected usingmultiple Opposing Y-V plasty. Patients were followed-up fora period of 6 months at least. All scar contractures werecorrected successfully in all cases. One partial flap necrosiswas observed and managed successfully with dressing changes.During the follow up period, only one case showed recurrenceof contracture and required release and local advancementflap. linear scar contracture treatment modalities vary largely.Options for reconstruction include skin grafts, Z plasty andY-V flaps. Skin grafts carry the risks of recurrence of contractures.Z plasty should include flap undermining before flaptransposition which carries the risks of flap necrosis especiallyin burned skin. Multiple Y-V flaps carry the advantages oflow rate of scar recurrence and secondary contractures andhave the merits of being a safe technique with low incidenceof flap necrosis. Running Opposing Y-V-plasty is an optionfor correction of linear cord-like burn scar contractures. Ithas the advantages of being a safe and effective method withlaw morbidity.

A Review of Perforator Flaps for Burn Scar Contractures of Joints.

Perforator flaps are one possible surgical treatment for burn scar contractures; however, a review of evidence on this topic is lacking. MEDLINE was searched for articles related to perforator flaps for burn contractures. Following title and abstract screen, full texts were searched to identify articles describing perforator flaps for burn scar joint contractures. Data were extracted and summarized descriptively. Only articles that contained ≥10 patients with burn scar contracture were considered. Two hundred forty-eight articles were identified, of which 17 met criteria for review. Of these, 16 were low-quality case series, while 1 was an open randomized controlled trial. In total, perforator flaps were performed on 339 patients (age range: 3-75 years), with the most common contracture locations being cervical (n = 218) and knee (n = 41). Nine of the 17 articles described a rehabilitation strategy. In general, functional outcomes were excellent, with the majority of patients experiencing return of normal joint range of motion and no recontracture. Compared to full-thickness skin grafts, perforator flaps showed greater improvements in joint range of motion. Cosmetically, perforator flaps were shown to have good color match with surrounding tissue, good contour around anatomical landmarks, and improved overall patient appearance. The most common complications were marginal flap necrosis (n = 26 patients) and venous congestion (n = 17 patients). Preliminary evidence from low-quality case series and 1 high-quality trial suggests perforator flaps may be successful for resurfacing released burn scar contractures; however, there is a need for additional trials comparing perforator flaps to other approaches.

97 Role of Early Splinting, Positioning, and Edema Control of Burn Effected Joints in the Prevention of Burn Scar Contracture

Burns involving joints can lead to debilitating contractures that can impair a survivor’s reintegration back into the work force and overall quality of life. There is lack of evidence supporting the timing and effectiveness of standard prophylactic treatment including splinting, positioning and edema control. This study seeks to determine contributing factors of early BSC and the efficacy of acute standard prophylactic interventions. The records of 300 patients within the Burn Patient Acuity Demographics, Scar Contractures, and Rehabilitation Treatment Time Related to Patient Outcomes (ACT) study from 2010–2013 were reviewed. Data abstracted included demographics, burn data, daily rehab interventions and discharge joint measurements. BSC was classified as none, mild (<30%), moderate (30–60%), or severe (>60%) based on normal joint passive range of motion. Univariate analysis and multi logistic regression (MLR) was used to determine the effect of contributing factors and BSC prevention methods on the incidence of BSC at hospital discharge. 266 (86.7%) patients were found to have BSC in at least one joint prior to discharge. Of the 3,279 joints analyzed, 44% had loss of range of motion (100 mild, 99 moderate and 60 severe). The most affected joints and movements were ankle dorsiflexion (128, 79% with BSC) and wrist flexion (117, 62% with BSC). Factors related to BSC were TBSA, surgery, length of stay (LOS), ICU days, bedrest days, and escharotomy/fasciotomy. Treatment factors included average daily hours of splinting, positioning, edema control and rehab. Only amount of skin grafted remained independently related to moderate or severe contracture on multivariable analysis. BSC occurs in a significant number of survivors during the initial phase of their burn injury. As the need for surgery is related to BSC formation, therapists should focus on these patients. Future studies are needed to refine the timing and efficacy of standard treatment for BSC. Therapists should concentrate efforts on the most severely injured patients.

331 The Power of Yoga: Clinical Outcomes and Cutaneous Functional Unit Recruitment for a Patient with Cervical and Upper Extremity Burn Scar Contracture

331 The Power of Yoga: Clinical Outcomes and Cutaneous Functional Unit Recruitment for a Patient with Cervical and Upper Extremity Burn Scar Contracture

A decade of Australian reconstructive burn surgery in Nepal 2004-2014

Nepal is a nation with an emerging economy that traditionally has faced challenges related to terrain, weather, political instability, natural disasters and poverty. It has a high rate of burn injury. Due to the above factors, adequate primary treatment of burns is frequently rudimentary, resulting in a significant burden of human suffering in the form of chronic debilitating burn-scar contractures. For several decades, international health teams have played a significant role in relieving the burden of disease and deformity, such as cleft lip and palate and burn-scar reconstruction. The current article summarises the experience of an Australian surgical team assembled to manage problems of burn-scar contracture in Nepal over the ten year period 2004-2014. The article discusses patient assessment protocola, patient statistics, conditions treated, procedures and results, complications.

A decade of Australian reconstructive burn surgery in Nepal 2004-2014

Nepal is a nation with an emerging economy that traditionally has faced challenges related to terrain, weather, political instability, natural disasters and poverty. It has a very high rate of burn injury. Due to the above factors, adequate primary treatment of burns is frequently rudimentary, resulting in a significant burden of human misery in the form of chronic debilitating burn-scar contractures. For several decades, international health teams have played a significant role in relieving the burden of disease and deformity, such as cleft lip and palate and burn-scar reconstruction. The current article summarises the experience of an Australian surgical team assembled to manage problems of burn-scar contracture in Nepal over the ten-year period 2004–2014.

Reconstruction of Post Burn Neck Contracture Using Full Thickness Skin Graft

Background: Neck contracture after burns is a major complication that affects function and cosmesis. The aim of covering the raw area and defects is through using good quality pliable skin. Full thickness skin graft allows a large dimension sheet of good quality skin with low donor-site morbidity. Also it provides similar skin quality to the recipient areas with much less cosmetic difference. Methods: Four men and eight women underwent neck contracture release and reconstruction from December of 2015 to August of 2016. Mean patient age was 29 years (range from 12 to 46 years). Burn scar contracture releases were performed and cervicoplasty was added for optimal neck appearance. Uniformly full thickness skin grafts were applied. Both lateral ends of these grafts (release incisions) were designed with a fishtail shape for sufficient release and to minimize linear scar band formation in the most lateral region of the neck. Results: Full thickness skin grafts as large as 24 ± 12 cm (in length) and 10 - 15 cm (in width) were used. All grafts were taken without significant complications. Range of neck motion increased, and the cervico-mental angle was regained in all patients. A highly natural neck contour was universally obtained without a secondary debulking procedure. Conclusions: Full thickness skin grafts for treatment of post burn neck contraction give good functional and cosmetic results. They give similar color match and good skin quality, also help in regaining of cervico-mental angle.

Angular Effects of Z-Plasty Technique on Extent of Relaxation of Contracted Scar, Cosmetic Appearance and Tip Necrosis in Dogs

Z-plasty is a plastic surgery technique which is used to improve the functional and cosmetic appearance of a scar by redirecting it into better alignment and allowing the closure of a large wound by increasing circumference of its orifices. This experimental study was executed to evaluate the extent of relaxation of contracted scar, cosmetic appearance and tip necrosis in dogs by using Z-plasty technique at different angles, i.e. 45°, 60° and 75°, respectively. 18 mongrel dogs were randomly selected and divided in three groups (A, B and C) comprising six dogs each; after induction of scar tissue, Z-plasty was applied at 45° in Group A, 60° in Group B and 75° in Group C, respectively. % Gain in length was superior for the 60° group (P<0.05), as compared with the 45° and 75° Z-plasty, respectively. Tip Necrosis Status and cosmetic appearance for the 60° group were also found superior (P<0.05) than at 45° and 75°, respectively. The results of the experimental trial showed that the parameters of extent of relaxation of the contracted scar, cosmetic appearance and tip necrosis, were mainly governed by two factors, (1) length of contracted scar and (2) angle of Z-plasty technique. Conclusively, 60° Z-plasty serves a better option for correction of burn scar contractures since it provides average gain in length, good cosmetic appearance and causes no tip necrosis.

Evaluation of Ideal Surgical Method for Management of Post Burn Scar Contracture of Neck

Evaluation of Ideal Surgical Method for Management of Post Burn Scar Contracture of Neck

A New Splint for Dorsal Foot Burns.

The treatment of dorsal foot burns has always been posed as a challenge to reconstructive surgeons. Despite of numerous reconstruction methods and appropriate approaches to the dorsal foot burn in acute phase, burn scars and contractures cannot always be prevented. Results of 5 female patients operated for burn scar contracture release and a new splinting approach are reported here.

Profile of Patients Without Burn Scar Contracture Development.

Burn scar contractures (BSCs) are a frequently recognized problem for survivors of burn injury. In the burn literature, many reports focus on the frequency and factors associated with the BSC development. To the contrary, few burn rehabilitation publications report on patients who are able to successfully avoid developing BSC. From a prospective, multicenter study, data were extracted and reviewed on a group of 56 adult burn survivors who were discharged from their acute hospitalization without any measured BSCs. Forty-three variables with a recognized or presumed association with the development of BSCs were analyzed and are reported. Highlighted features of the noncontracted group included being an adult male with an educated background and few associated physical, medical, or social problems. The group had relatively small burn sizes that nonetheless required hospitalization. Despite the overall TBSA, the majority of the burn areas required skin grafting, although this area also represented a small area. The patient group had a longer than expected hospital stay. Rehabilitation was provided to patients on 80% of their hospital days. In addition, patients received sufficient rehabilitation treatment based on the number of cutaneous functional units involved in the burn injury. Patients were judged to have a high pain tolerance and compliant with rehabilitation. The results of this study document the clinical circumstances that patients with burn injury can be discharged from their acute hospitalization with the development of BSC. This study challenges the rehabilitation personnel to expand the upper limit of burn severity that can result in similar positive outcomes.

Development of International Outcomes Instrument for Hand and Upper Extremity Burn Scar Contracture Release.

Burn scar contractures remain a common source of severe disability in resource-limited countries. However, existing outcome measurements are unable to fully capture the impact of the scar contracture and surgical attempts at correction. To that end, we have developed a new outcome instrument, the Stanford-ReSurge Burn Scar Contracture Scale-Upper Extremity that can be used as a measurement of disability and reconstructive procedure outcomes. The outcome instrument was created through item generation, item reduction, and preliminary field testing. We performed a literature review using multiple databases to gather a comprehensive list of existing burn contracture metrics, removed metrics that were inapplicable in resource-limited settings, and submitted remaining items to plastic and hand surgeons for evaluation of clinical and cultural relevance, comprehensiveness, and feasibility. The remaining items were field tested to evaluate patient comprehension and ability to detect change over 1 month. A literature review found 32 unique scales that were eventually reduced to a pool of 38 potential items that were field tested with patients. Patient feedback further reduced the item pool to the final 20-item scale. Patients who underwent burn scar contracture release of the upper extremity showed an average of 14 points improvement between the preoperative and 1-month postoperative time point. The Stanford-ReSurge Burn Scar Contracture showed clinical utility for assessing outcomes in burn scar contracture release of the upper extremity. Our goal is to develop a standardized outcome instrument for burn reconstruction in the world's poorest burn patients.

Burn Patient Acuity Demographics, Scar Contractures, and Rehabilitation Treatment Time Related to Patient Outcomes: The ACT Study.

In 2008, the U.S. Department of Defense funded a rehabilitation study through the American Burn Association titled "Burn patient acuity demographics, scar contractures, and rehabilitation treatment time related to patient outcomes," commonly known at the ACT study. The ACT was a multi-institutional, prospective, observational, and quasirandomized investigation of the acute hospital course of 307 patients. The ACT specifically emphasized the capture of factors that may impact the physical outcome of patients with burn injury including burn severity, daily rehabilitation interventions such as mobility and splinting, and detailed skin grafting episodes. In particular, the effect that the amount of daily rehabilitation time patients received as it related to range of motion measured at the time of acute hospital discharge of areas affected by the burn injury was analyzed. The information contained herein is intended to give the interested reader an overview of the extent and breadth of the ACT dataset in terms of parameters available for further investigation. This information is also intended to be used as a basic reference for conduct of the ACT study in future reports.

A Study of Reconstruction of Axillary Burn Scar Contracture with Scapular and Parascapular Flaps

A Study of Reconstruction of Axillary Burn Scar Contracture with Scapular and Parascapular Flaps

The Stanford-ReSurge Burn Scar Contracture Scale for Neck: Development and Initial Validation for Burn Scar Contracture.

Burn contractures can cause significant disability, particularly in patients in resource-limited settings. However, a gap exists in our ability to measure outcomes in patients with burn contractures of the neck. The objective of this study was to develop and validate the Stanford-ReSurge Burn Scar Contracture Scale-Neck to longitudinally assess functional status and measure functional improvement following contracture release of the neck. A literature review was performed to identify scales used in neck assessment and burn assessment. Items were then removed from the pool based on redundancy, feasibility, cultural appropriateness, and applicability to patients in international resource-limited environments. Remaining items were administered to patients with burn contracture of the neck. The initial literature review found 33 scales that were combined to create an initial pool of 714 items, which was first reduced to 40 items. Feedback from field testing then yielded a 20-item outcome tool to assess appearance, activities of daily living, somatosensation, satisfaction, and range of motion, with a floor of 20 and a ceiling score of 100 points. Preliminary testing with 10 patients showed an average preoperative score of 58 points and an average 1-month postoperative score of 42 points. The authors have created an outcome tool for measuring functional status following burn contracture release of the neck, which can easily be implemented in resource-limited settings where the burden of burn injuries and morbidities is disproportionately high. Ongoing work includes a multicountry study to evaluate validity and reliability.

Cutaneous Functional Units Predict Shoulder Range of Motion Recovery in Children Receiving Rehabilitation.

Cutaneous functional units (CFUs) are fields of skin that functionally contribute to range of motion (ROM) at an associated joint. When replaced with scar tissue, the skin is less extensible and may result in loss of movement at the joint. Consideration of the amount of CFU affected by burn injury is increasingly being used to predict the development of burn scar contracture (BSC) in burn survivors. Previous work established that, in adults, burn rehabilitation time per CFU was the greatest predictor of preventing BSC. Our study aimed to examine the direct relationship between percent involvement of CFU and ROM achieved in children with BSC who received 6 months of rehabilitation therapy services. ROM was measured at baseline and throughout the study period using traditional methods of goniometry as well as three-dimensional motion capture during the performance of functional tasks. Burn extent and distribution were mapped using an electronic diagram to calculate the percentage of CFU affected by scarring or skin grafts. Pearson's correlations and multivariate linear regression analyses were performed to determine associations between variables. Results showed that percent CFU involvement was negatively correlated with maximal goniometric and functional shoulder ROM achieved. That is, the amount of a given CFU scarred was predictive of less ROM achieved in the associated area. Percentage of CFU involved did not significantly correlate with baseline shoulder ROM, suggesting that other factors may be associated with initial limitations in ROM. Evaluation of the percentage of CFU scarred is useful for predicting shoulder ROM recovery with rehabilitation and may be used to help guide clinical decision making and allocation of time and resource for therapy services.

Abstract: Development and Field-Testing of an Alternative Low-Cost Hand Splint for Burn Contracture

INTRODUCTION: Burn scar contractures remain a common source of disability in low- and middle-income countries and often require complex reconstructive operations to restore function to the patient.1 Despite the high prevalence of burn scar contractures and subsequent release procedures, patients often face tremendous barriers to adequate physical therapy and follow-up care, which results in relapse of the contracture following a release.2,3 Static progressive splinting mechanisms are well-described for this indication4, but these splints are cost-prohibitive or unavailable to patients in low- and middle-income countries. To that end, we describe our work to develop and test an alternative low-cost static progressive hand splint designed to prevent flexion re-contracture in burn scar contracture release patients. METHODS: The splint was created through an iterative design-and-test process through collaboration with Stanford School of Medicine in the US, Kirtipur Hospital in Nepal, and Scheer Memorial Hospital in Nepal. Splints were given to Nepali patients who underwent burn scar contracture release of the palmar hand and would not be able to return to the hospital for long-term physical therapy after their surgery. Patients were instructed to wear the splint at night for six months and to progressively extend the splint’s ratchet mechanism as tolerated. Patients were assessed for range of motion and hand function pre-operatively, one week post-operatively, and three months post-operatively. RESULTS: The initial prototype underwent multiple rounds of iterative design and feedback from patients for comfort, fit, and durability. Patients demonstrated good compliance with the splinting regimen and expressed satisfaction with the fit and durability of the device. Preliminary follow-up suggests that patients using the splint maintain post-operative range of motion without additional re-contracture. CONCLUSION: We have created a hand splint to prevent flexion recontracture following burn scar contracture release of the hand. Ongoing work includes six-month follow-up to ensure maintenance of improved range of motion and testing in other indications including Dupuytren’s contracture and stroke. DISCLOSURE/FINANCIAL SUPPORT:Supported by the Design Lab at Stanford University. None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this abstract. REFERENCE: 1. Bhattacharya, S., 2013. Avoiding unfavorable results in postburn contracture hand. Indian J. Plast. Surg. Off. Publ. Assoc. Plast. Surg. India 46, 434–444. doi:10.4103/0970-0358.118625 2. WHO | World report on disability. at http://www.who.int/disabilities/world_report/2011/en/ 3. Kucan, J.O., Bash, D., 1992. Reconstruction of the burned foot. Clin. Plast. Surg. 19, 705–71 4. Schultz-Johnson, K., 2002. Static progressive splinting. J. Hand Ther. Off. J. Am. Soc. Hand Ther. 15, 163–178.