Web Space Contracture Research Articles

Distraction assisted management of post burn contracture of hand

Burns are one of the injuries that causes significant morbidity and reduced quality of life.Despite making up only 3% of the body's surface area, hands are involved in more than 80% of serious burs. Scarring, joint contractures and stiffness are devastating in the upper extremity due to its dependence. In this article, we have used Distraction assisted management is one of the methods for the management of finger webspace contracture release. In this case, we will be using a JESS distractor in the management of web space contracture in the upper extremity.

Primary care doctor’s perception about the scope of plastic surgeons: A national survey

Plastic surgery is characterized by a broad spectrum of aesthetic and reconstructive surgical expertise that is not defined by an anatomic area. The authors sought to identify primary care doctors' perceptions of different fields of plastic surgery. A short, anonymous, web-based survey was administered to primary care doctors in Portugal. Respondents were asked to choose the specialist they perceived to be an expert for 29 specific clinical areas, including 20 that are the core of plastic surgery practice. Specialists for selection included the following choices: dermatologist, general surgeon, maxillofacial surgeon, vascular surgeon, neurosurgeon, orthopedic surgeon, otolaryngologist, and plastic surgeon. A total of 430 complete answers to the survey were collected. Out of the 20 clinical cases related to plastic surgery, only nine were attributed to plastic surgery in the majority of the answers: thumb reimplantation (64,2%), abdominoplasty (93%), breast reduction (94%), otoplasty (62,3%), skin graft for a burn (97,7%), breast reconstruction (94,9%), complex open wound (57,2%), facial reanimation (36,7%) and first web space contracture of the hand (78,6%). There is a clear underestimation of the role of plastic surgery in a wide range of conditions, which may lead to the downsizing of plastic surgery departments in the national health system. It is of utmost importance to educate primary care doctors so that patients are referred correctly and in a timely manner.

564 Simplified Dynamic Splints for Common Scar Contractures of the Hand

Abstract Introduction Common problems associated with immature burn scarring of the hands include proximal interphalangeal (PIP)/distal interphalangeal (DIP) flexion contracture, first webspace contracture, and metacarpal phalangeal (MCP) hyperextension that require diligent splinting intervention in therapy and at home to improve patient outcomes. Dynamic splinting can be used to provide low-load long-duration stretch; however, they can be difficult for patients to don independently at home and are often time consuming for therapists to fabricate. Alternative methods of using neoprene strapping were utilized to provide the dynamic pull to simplify the supplies required and improve ease of use for the patient. Methods Using the “I splint” for elbow flexion contractures as a model, we fabricated a smaller version for use in finger PIP and DIP flexion contractures using thermoplastic material and neoprene strapping (Figure 1a). A novel splint for thumb abduction/extension in treatment of first web space scar contracture (Figure 1b). Based on a traditional MCP flexion splint, we utilized neoprene strapping instead of springs or rubber bands and a plastic D ring instead of metal outrigger (Figure 2). Splint wear started at 1x/ day for 5 minutes and progressed to 3-5x/day for 5-15 minutes as tolerated. Results Digit PIP or DIP extender (figure 1a.) after 1 week of daily wear improved PIP extension from 45 degrees (of flexion) to 25 degrees and DIP extension from 50 degrees to 30 degrees. Thumb Post Splint (figure 1b.) after 2 weeks of daily wear improved radial abduction from 45 degrees to 58 degrees. Dynamic MCP flexion splint (figure 2) after 1 month of daily wear improved left ring finger active MCP flexion from 0-20 degrees to 0-40 degrees. Left small finger active MCP flexion improved from (-50) - 0 degrees to (-40) - 5 degrees (negative parenthetical value denotes hyperextension). Conclusions Dynamic splints utilizing neoprene strapping contributed to improved range of motion for all patients included in this case series. Therapists noted that splint adjustments were infrequent and minimal throughout time of use. Patients reported ease of use and compliance with splint wear schedule outside of therapy sessions. The amount of time spent fabricating compared to traditional methods was not tracked and would be an interesting point to consider in the future. Applicability of Research to Practice We hope that this presentation may give other practitioners new tools to address common burn scar contractures of the hand and simplify both the fabrication process and materials required for dynamic splinting.

First web space plasty using Ilizarov mini fixator in patients with complex hand injuries

Effective treatment and rehabilitation of complex hand injuries are often challenging. Various corrective techniques and approaches have been proposed for the first web space contractures based on a classification system, however, consensus regarding optimal management does not exist. In this study, we evaluated twelve consecutive patients with the mean age of 46.72 years who underwent first web space dilatation using Ilizarov mini fixator from 2009 to 2020. The tip length during radial/palmar abduction and radial/palmar abduction angles were measured preoperatively, after instrumentation, and in the last follow-up. The average thumb-index finger distance during Passive Radial Abduction (PRA) increased from 4.3 to 9 cm, and the distance during Passive Palmar Abduction (PPA) decreased from 10.2 to 9.22 cm, the average passive radial abduction angle (PRAA) of the first web space increased from 21.6 to 58.3°, Active Radial Abduction Angle (ARAA) from 20.0 to 49.7°. The average Passive Palmar Abduction Angle (PPAA) increased from 32.5 to 59.1°, and Active Palmar Abduction Angle (APAA) from 30.9 to 47.7° after using Ilizarov mini fixator. Ilizarov mini fixator provides promising outcomes with the optimal range of motion in severe first web space contractures. • Patients with severe first web space contractures were treated and followed. • The duration of this study was from 2009 to 2020. • We used unidirectional and bidirectional Ilizarov mini fixators for our patients. • Radiographic parameters were evaluated preoperative, at the time of fixator removal and in latest follow up. • Radial and Palmar Abduction parameters were significantly improved at the time of final follow up.

Surgical Modalities for Post Burn First Web Space Contracture Reconstruction

Surgical Modalities for Post Burn First Web Space Contracture Reconstruction

Square Flap Method for Reconstruction of Palmar and Dorsal Web Space Burn Contractures.

Postburn web space contractures can result in serious in hand function impairments along with cosmetic disfigurement. In our study, we introduce our experience with the use of the square flap method to release palmar or dorsal web space contractures. From March 2019 to May 2021, the square flap method was conducted in 12 patients with 13 digital web space contractures. The average patient's age was 6 years old (range, 2.5-16 years old). The most common affected web space was the second web. Web contractures were palmar in 9 patients and dorsal in 4 patients. The average duration of scar maturity was 13.6 months (range, 8-24 months). All the square flaps were effective in releasing the web space contracture and healed uneventfully with no postoperative complications. The average follow-up period was 11 months (range, 2-24 months). All patients or their parents were satisfied with the procedure outcomes in terms of independent finger function and esthetic appearance. The square flap technique is safe, reliable, and effective in management of both dorsal and palmar interdigital web scar contracture. It completely eliminates the contracture and restores commissural anatomy with good cosmetic outcomes.

A novel technique to widen the 1st web space by using 'spare parts' of thumb polydactyly

First web space contracture causes significant morbidity and hence their release is important to make use of normal hand functions. First web space helps in improving the grasp. There are several methods of normalizing the 1st webspace. In this article we are describing a local flap that uses the spare tissue of the thumb polydactyly for recovering the defect created from the release of the first web contracture, thereby providing coverage with a tissue that has good vascularity and also giving sensation to the resurfaced part.

Correction of hand deformities after burns

Hand burns can lead to deformities even after successful primary healing. They are the most common cause of skin contracture involving the hand. This review article discusses ways to correct claw deformity, flexion contracture in the palm and finger, and web space contracture, which are post-burn hand deformities commonly encountered in clinical practice. Loss of skin is the end result in many cases of hand deformities after burns. Therefore, reinforcing the lost skin is the principle of corrective surgery. Even if the skin is thicker than the full-thickness skin, it will engraft if damage to the tissue and blood vessels of the recipient is minimized. The thicker the skin, the less re-contraction and growth occur. The foot is an ideal donor site for skin grafts on the hand. In particular, the instep or the area below the malleolar is a very good donor site. The first web space of the hand is very important for hand function, and it must be reconstructed with Z-plasty, a skin graft, and a free flap step by step according to the degree of contraction.

Use of Autologous Skin Cell Suspension for the Treatment of Hand Burns: A Pilot Study

PurposeAutologous skin cell suspension (ASCS) is a valid alternative and adjunct to split-thickness skin grafting (STSG) for treating burns. Limited data exists regarding the use of ASCS for hand burns. We hypothesized that using ASCS in hand burns shortens healing time with no difference in complications and less donor site morbidity.MethodsThis was a retrospective chart review of second- and third-degree hand burns treated at a level 1 Trauma and Burn Center from 2017 to 2019. Study groups included patients with hand burns treated with ASCS in combination with STSG and those treated with STSG alone. Outcomes included time to re-epithelialization, return to work, length of hospital stay, and complications including reoperation, graft failure, and infection.ResultsFifty-nine patients aged 14 to 85 years (mean age 39 ± 15 years) met inclusion criteria. The ASCS treatment group comprised 37 patients; STSG comprised 22 patients. Mean follow-up time was 14 ± 7 months. The ASCS treatment group had a larger mean percent total body surface area (TBSA) (22% ± 14% vs 6% ± 8%; P < .05). There was no difference in time to wound re-epithelialization between both groups (ASCS, 11 ± 4 days vs STSG, 11 ± 5 days). Mean length-of-stay was 23 ± 13 days compared to 10 ± 13 days (P < .05) between the ASCS and STSG groups, respectively. No patients in the ASCS group required reoperation, whereas 2 patients in the STSG group required such for an infection-related graft loss and a web space contracture release. On multivariable analysis adjusting for TBSA, ASCS was associated with an earlier return to work (P < .05).ConclusionsASCS is safe and effective in treating hand burns. ASCS was associated with similar rates of re-epithelialization, earlier return to work, and no difference in complications compared with STSG.Type of study/level of evidence: Therapeutic IV.

Osteoarthritis of the Thumb Basilar Joint

Osteoarthritis of the thumb basilar joint is a common pathology treated by hand surgeons, and this is the leading cause of degenerative pain in the hand. Multi-factorial etiologies, including occupational stresses, gender, hormone milieu, and altered biomechanics, may play roles in the development of thumb carpometacarpal (CMC) joint arthritis. Patients present with aching pain, synovitis, weakened pinch and grip, and in late disease, adduction deformity and web space contracture. Physical examination and plain radiography are the mainstay of diagnosis, with little utility for advanced imaging. A multitude of options exists for conservative treatment: physical therapy, splinting, anti-inflammatories, and injections. With the failure of conservative therapies, surgical management is dictated by disease severity and provider preference. The thumb CMC joint hosts a variety of treatment options that have evolved over time: arthroscopy, osteotomy, arthrodesis, trapeziectomy alone, or with combinations of ligament reconstruction and tendon interposition. No superiority has been shown amongst the many base of thumb treatment modalities, though trapeziectomy alone demonstrates a lower complication rate. This review contains 5 tables, 3 figures, and 61 references. Keywords: hand osteoarthritis, base of thumb, anatomy, arthroplasty, silicone, arthrodesis, tendon reconstruction, biomechanics, tendon interposition, outcomes

111 Predicting Restoration of Joint Function in the Contracted Burned Hand: The Benefit of the Soft Tissue to Skeletal Ratio

Abstract Introduction Long-standing burn contractures of the hand produce marked soft tissue deficits across mobile joint surfaces. Optimum functional reconstruction requires attention to the ratio of soft tissue contracture to skeletal length. Maturation of burn scar and anticipated growth in children play a role in selecting procedures that maximize function and range. Methods Burn contractures of the hand show functional loss of motion by flexion/extension deformities of the fingers and wrist. Analysis of soft tissue shortening (contraction), measured against existing skeletal length was used to customize procedures to restore maximum function. Twenty six patients, aged 3 to 57 years underwent post burn reconstruction to maximize hand function. Each procedure selected was based on the ratio of existing soft tissue to skeletal length. Results Flexion/extension at all joints requires a balanced glide of soft tissue over existing bone length defining a 1:1 ratio between soft tissue and skeletal length. Burn contracture shortens soft tissue and restricts motion over joints. An objective ratio was applied to each joint contracture. A comparison of soft tissue quality to skeletal length (including growth in children) was used to determine the procedure for reconstruction associated with the best prognosis for maximum outcome with the least recurrence. Abnormalities included post burn boutonniere deformities, webspace contractures, flexion and extension contracture deformities of the hand, and digits. Burn scar hypertrophy and induration worsened the ratio. Eight patients with a soft tissue to skeletal ratio of 0.4:1 or less required bone shortening in the form of either joint arthrodesis, trapeziectomy, or wrist fusion. Twelve patients with a ratio of 0.7:1 or better were managed with skin grafts and/or adjacent tissue rearrangement. In the remaining group, four patients required a combination of procedures including composite soft tissue and tendon expansion restoring length of all soft tissue relative to bony length precluding the need for flap reconstruction and tendon lengthening. Two patients underwent bone shortening with prosthetic joint replacement. All patients restored to a 0.8:1 ratio or better regained optimum position of joint position and function. No secondary procedures were required for deterioration of function at two years. Conclusions A balanced dynamic soft tissue to skeletal ratio is essential in restoring maximum function to the burned hand. Understanding soft tissue contraction compared to existing bone length will permit the objective design of a reconstructive hand/finger procedure that will predict outcome and maximize hand function. Applicability of Research to Practice Predicable outcomes of functional hand reconstruction are possible based on the relationship of burn scar contracture to measurable skeletal length.

Free Posterior Interosseous Artery Flap for Treatment of First Web Space Contracture: Methods of Venous Anastomosis

Free Posterior Interosseous Artery Flap for Treatment of First Web Space Contracture: Methods of Venous Anastomosis

Commonly Used Assistive Devices in Neurological Conditions

Background: Assistive devices used externally which made for adaptation with appropriate assisted an impaired person to perform their daily functions. It may be simple, low cost types and also controlled by specialized computer software. Various types of positional devices, mobility devices, daily living devices & also prosthetics, orthotics were used for support. Some evidence suggested that assistive devices helped for ambulation & ambulatory function assessment should be depending on the requirements of assistive device uses in neurological conditions especially on stroke and SCI. Study focused that applicationof stretch splint on experimental thumb where reduced the space. But resultshowed that intensive stretch which applied regularly for three months did not reduce thumb web-space contractures. On the other hand, other study suggested everyday used of assistive devices with environmental modification improves GMFS levels in CP children. Another RCT discussed that h-AFO may reduce toe walking on the hemi paretic side into a heel–toe gait pattern & it also controlled excessive ankle plantar flexion in swing phase. This study also focused that h AFO was more effective than dynamic AFO in gait rehabilitation for hemiplegic CP. Objective: To focus on the uses of assistive devices in neurology. Methodology: Study was done by narrative review. Conclusion: Assistive device helped a physiotherapist to achieve maximum goal during rehabilitation in neurological conditions. Some assistive devices were used for treatment purpose as well as ADL modification & it improved, maintain their quality of life. But it was very much important to know the proper use of devices with their rational and important concerning issue about the overuses and inappropriate uses of assistive devices which may lead to more dependency of neurological patients and also negatively impact on their rehabilitation process. If more RCT will be done about the use and effect of assistive devices may help us to clear conception about the uses of assistive devices and its importance on rehabilitation of neurological conditions.

Upper limb congenital muscular hypertrophy and aberrant muscle syndrome in children.

IV.

Ulnar Thumb Pulp Reconstruction Using the Anterograde Homodigital Neurovascular Island Flap.

The thumb ulnar pulp is a critical component of key pinch and precision manipulation. Injuries to this area should be reconstructed with robust, sensate tissue that restores bulk and contour. The existing reconstructive options, however, have substantial risks and drawbacks. We describe an anterograde homodigital neurovascular island flap that provides both sensate and durable coverage of the ulnar thumb pulp. The flap uses innervated glabrous tissue, limits donor site morbidity to the thumb and first web space, and does not require microvascular anastomoses or nerve coaptation. The flap has been previously described for nonthumb fingertip injuries, but it has not been applied to the thumb. We discuss several important technical modifications that are essential to raising and insetting this flap in the thumb, review potential pitfalls, and highlight key steps to ensuring judicious intraoperative decision making and success.

Severe Hand Injuries From Fireworks: Injury Patterns, Outcomes, and Fireworks Types

The purpose of this study was to characterize injury patterns and outcomes of fireworks-related hand injuries and determine if there was an association with certain fireworks types. A retrospective cohort study was conducted on patients treated at a trauma center between 2005 and 2015. A total of 105 patients sustaining operative hand injuries due to fireworks were identified. Medical records were reviewed to identify injury patterns, treatment outcomes, and fireworks types. Eighty-eight patients (84%) sustained 92 thumb and/or first web space injuries. There were 12 thumb soft tissue-only injuries (13%) and 80 thumb fractures/dislocations (87%). Of these, there were 52 thumb carpometacarpal (CMC) joint dislocations (57%) and 36 thumb fractures outside the thumb CMC joint (39%). Fifteen hands (16%) sustained both thumb CMC joint dislocations and additional thumb fractures. Twenty-three hands (25%) required thumb revision amputation. The number of surgeries for acute reconstruction ranged from 1 to 7, with 17 patients (19%) requiring 3 or more. Sixty-three hands had deep first web space injuries, and 11 (17%) required flaps acutely for first web space reconstruction. Six hands required secondary reconstruction of a first web space contracture. An external fixator was applied to 6 hands to maintain the first web space; none of these required secondary web reconstruction. Excluding isolated pin removals and dressing changes under anesthesia, 19 patients (22%) required later-stage surgeries. Shells/mortars (59%) were the most common fireworks type causing injury. Among operative hand injuries, fireworks most commonly fracture the thumb, destabilize the thumb CMC joint, and deeply damage the first web space. The first web space requires particular consideration because deep injury may result in adduction contracture and require secondary reconstruction if not prevented. Therapeutic IV.

Abstract: Analysis of Thumb and First Webspace Injuries Due to Fireworks

INTRODUCTION: Fireworks-related hand injuries can be devastating. We hypothesize that thumb and first webspace injuries are common among fireworks blasts and have distinct patterns of injury. MATERIALS AND METHODS: We reviewed our hospital database to identify patients with fireworks-related injuries from 2005–2015. Patients with operative hand injuries were included. Chart review identified demographic information, injury characteristics, and operative details. RESULTS: 105 patients had operative fireworks-related hand injuries. There were 102 males, 3 females, and mean age was 28 years. 6 underwent complete hand amputation through wrist or forearm. 16 patients (16%) had bilateral injuries. In the thumb and/or first webspace injury group, 88 patients (84%) sustained 92 hand injuries and there were: 80 thumb fractures, 8 thumb soft tissue-only injuries, 52 thumb carpometacarpal (CMC) joint fracture dislocations, and 36 thumb fractures outside the thumb CMC joint. 15 had both thumb CMC joint fracture dislocations as well as additional thumb fractures. 23 required thumb revision amputation. 63 hands had deep first webspace injuries, and 11 required flaps for first webspace reconstruction. 6 required secondary reconstruction of a first webspace contracture (4 local tissue rearrangement, 1 flap, 1 skin graft). An external fixator was applied to 6 hands to maintain the first webspace; none of these required secondary web reconstruction. The number of surgeries for acute reconstruction ranged 1 to 7 (mean 1.6), with 19% requiring 3 or more. Later-stage surgeries included: pin removal (35), flap debulking (1), tenolysis (3), osteotomy (2), nail ablation (2), stump revision (5), flap (groin or toe transfer) (3), neuroma excision (1), digital nerve reconstruction (1), capsulotomy (5), first webspace deepening (6), dressing changes in children (3). Excluding isolated pin removals and dressing changes under anesthesia, 17 patients (20%) required later-stage surgeries. CONCLUSION: Thumb injuries from fireworks result from high-energy avulsion, hyperextension, and hyperabduction, frequently injuring the thumb, destabilizing the CMC joint, and seriously damaging the first webspace. The first webspace requires particular consideration as deep injury may result in adduction contracture and require secondary reconstruction with tissue outside the zone of injury if not prevented. In our experience, application of thumb stabilization with either a miniature external fixation device or Kirschner wires to stabilize the CMC joint is imperative to maintain the first webspace and prevent thumb adduction contracture. DISCLOSURE:None

Prevention of Thumb Web Space Contracture With Multiplanar External Fixation.

Thumb web space contracture following hand trauma can be disabling with numerous reconstructive procedures existing to correct the resultant deformity. Following marked soft tissue injury to the hand we utilized the Stryker Hoffmann II Micro External Fixator System to link the first and second metacarpals by a multiplanar system using 1.6 or 2.0 mm self-drilling half-pins and 3 mm carbon fiber connecting rods. This facilitated placement of the thumb in maximal palmar abduction as well as allowed adjustment of thumb position throughout the postoperative period. This technique was performed on 5 patients. Two patients were treated with a first web space external fixator for table saw injuries to the radial aspect of the hand. An additional 2 patients were treated with a first web space external fixator following metacarpophalangeal joint capsular release in the setting of thermal burns. A fifth patient underwent second ray amputation, trapeziectomy and trapezoidectomy for squamous cell carcinoma with subsequent stabilization with the external fixator. The external fixator was left in place until soft tissues were healed (average 5.5 wk). The patients were allowed to mobilize their hand in as much as the external fixator allowed, and no device-associated complications were noted. Thumb web space was preserved with passive and supple thumb circumduction and web space abduction/adduction in all patients at an average follow-up of 5 months. The average Quick Dash Score was 35±5 and the average Modern Activity Subjective Survey of 2007 was 30±8.

RECONSTRUCTION OF POSTBURN CONTRACTURE OF FIRST WEB SPACE OF THE HAND

Background: Soft tissue reconstruction of the first web space remained a challenge for plastic and reconstructive surgeons. First web space adduction contractures are a common consequence of hand burns. Many reconstructive techniques are used and investigation for more effective methods continues. Objective: assess the range of movement as regard opposition, palmar abduction and thumb extension. Also assessed the depth of web space after reconstruction of post burn contracted first web space to ass the method of covering the defect after release.. Materials and Methods: 35 patients’ ages ranged from 12 to 59 years (with mean 31.7), years; 23 males and 12 females admitted to our Hospital during the period from June 2008 to May 2012. All patients were suffering from post-burn first web contractures. The patients underwent a variety of surgical procedures. The follow-up period ranged from one to three years. Results: Full range of motion achieved in most patients, but not those with joint affections. Conclusions: In our experience, surgical correction of first web space contractures- in the form of flaps good results followed by skin grafts- results in meaningful functional enhancement. The outcomes depend primarily on the severity of contracture. Functionally limiting recontracture is rare in our experience and its best prevented by appropriate therapy Keywords: Contracture; Burns; First web space reconstruction.

Combination of rhomboid flap and double Z-plasty technique for reconstruction of palmar and dorsal web space burn contractures

BackgroundWeb space contractures after a burn can cause severe impairments in hand function along with esthetic deformities. In this study we present our experience with the combined treatment technique consisted of rhomboid flap and double Z-plasty for palmar and dorsal web space contractures. Materials and methodsCombined rhomboid flap and double Z-plasty was performed in eight patients with eleven web space contractures occurred after burn. The average follow-up was 10.9 months. ResultsThe average age of 8 patients was 16.3 years. The average duration of burn contractures was 6 years (range 1–13 years). The right third web of the patients was the most common contracted web space. In the postoperative period hematoma, infection, partial or total flap loss was not observed in any patient. Web and hand function and esthetic appearance of web spaces were satisfactory in the late postoperative period. ConclusionRhomboid flap combined with a double Z-plasty technique was an effective choice for the treatment of palmar and dorsal web space contracture after burn.