|Year : 2014 | Volume
| Issue : 2 | Page : 1-5
Inventory of potential reconstructive needs in patients with post-burn contractures
Abdulrasheed Ibrahim1, Ferdinand O Ijekeye2, Malachy E Asuku1
1 Department of Surgery, Division of Plastic Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria
2 Department of Surgery, Division of Plastic Surgery, University of Benin Teaching Hospital Benin, Edo state, Nigeria
|Date of Web Publication||15-Apr-2015|
Department of Surgery, Division of Plastic Surgery, PMB 06 ABUTH Shika Zaria Kaduna state
Source of Support: None, Conflict of Interest: None
Background: The inventory of potential reconstructive needs records the specific reconstructive needs of the patient with burns and allows systematic planning for future reconstruction and rehabilitation. It also assists patients to evaluate and prioritize reconstructive options with the guidance of the plastic surgeon, as well as facilitating the adoption of realistic expectations on the part of the patient and family.
Materials and Method: A survey of the potential reconstructive needs was carried out using the inventory of reconstructive needs form. The form is applicable to all body regions and is divided into three sections. Each section is subdivided into anatomic units: head and neck (anatomic units 1-5); upper extremity (anatomic units 6-9); and trunk and lower extremity (anatomic units 10-13). The results are presented in tabular form and analyzed using simple frequency distribution.
Results: The anatomic region with the highest number of reconstructive needs was the head and neck in adults 25 (42%).The trunk and lower extremity accounted for the least reconstructive needs in adults 12 (20%). When the reconstructive needs were stratified by anatomic units in the head and neck, the upper eyelids 8 (32%) and the neck 6 (24%) had the highest frequency of reconstructive needs in adults. The upper extremity had the highest reconstructive needs in children 51 (52%). The upper eyelid, mouth and neck accounted for 13 (76%) of the reconstructive needs in children. Seventy-eight (50%) of the 157 patients had at least two contractures.
Conclusion: There were more reconstructive needs in children than adults. The anatomic region with the highest number of reconstructive needs was the head and neck in adults and the upper extremity in children. This study underscores the importance of positioning and intensive therapy intervention in the prevention of post-burn contractures.
Keywords: Adults, children, inventory, post-burn contracture, reconstructive needs
|How to cite this article:|
Ibrahim A, Ijekeye FO, Asuku ME. Inventory of potential reconstructive needs in patients with post-burn contractures. Nigerian J Plast Surg 2014;10:1-5
|How to cite this URL:|
Ibrahim A, Ijekeye FO, Asuku ME. Inventory of potential reconstructive needs in patients with post-burn contractures. Nigerian J Plast Surg [serial online] 2014 [cited 2019 Dec 8];10:1-5. Available from: http://www.njps.org/text.asp?2014/10/2/1/155165
| Introduction|| |
Despite advances in the overall management of burn injuries, post-burn contracture continues to plague survivors of burn injuries and remains a formidable foe of reconstructive surgeons. ,, Functionally, contractures of the upper extremities may affect activities of daily living, such as grooming, dressing, eating, and bathing, as well as fine motor tasks. Contractures of the lower extremities interfere with transfers, seating, and ambulation. ,, As a wider range of reconstructive surgery techniques are becoming increasingly available and effective in minimizing these sequelae, accurate documentation of the distribution and severity of reconstructive needs is essential to achieve optimal functional and aesthetic results.  Current techniques of documentation have not been adequate. The medical records and discharge summary notes of patients are not succinct in the determination of potential reconstructive needs.
The inventory of potential reconstructive needs records the specific reconstructive needs of the patient with burns and allows systematic planning for reconstruction and rehabilitation.  It is a unique tool in the assessment of patients with post-burn contractures because it offers a comprehensive consideration of all the somatic abnormalities as well as a system for grading the severity.  In addition, it assists patients to evaluate and prioritize reconstructive options with the guidance of the plastic surgeon, as well as facilitating the adoption of realistic expectations on the part of the patient and family.  The inventory also has potential research value. It is a template for documenting long-term functional and cosmetic consequences over a number of years. ,
A review of the literature revealed a number of publications describing experience with reconstructive procedures in the burn patient. ,,, However, there is a paucity of publications on the potential reconstructive surgery needs of the burned patient. The objective of this study is to establish the reconstructive needs in patients presenting with post-burn contractures in a tertiary institution in Nigeria.
| Materials and Method|| |
This prospective cross-sectional study involved all patients with contractures following burns. The study was conducted at the out-patient clinic of the Burns and Plastic Surgery Unit of the Ahmadu Bello University Teaching Hospital, Zaria-Kaduna State, Nigeria, between March 2009 and April 2012.
A survey of the potential reconstructive needs of the patients with post-burn contractures was carried out using the inventory of reconstructive needs form. Items in the form were adapted from the original Inventory of Potential Reconstructive Needs developed by Brou, et al.  The form is applicable to all body regions and is divided into three sections. Each section is subdivided into anatomic units: head and neck (anatomic units 1-5); upper extremity (anatomic units 6-9); and trunk and lower extremity (anatomic units 10-13) [Appendix 1]. The inclusion criteria were all patients with post-burn contractures. Patients with pre-existing physical disability were excluded. Participants at the beginning of the study were given information on the nature of the study, the participants' right to withdraw from the study at any time and confidentiality of personal data. In order to maintain confidentiality, the forms were made anonymous. The results are presented in tabular form and analyzed using simple frequency distribution.
| Results|| |
There were 157 patients, 60 adults and 97 children. The age of the patients ranged from 2 to 46 years. A total of 341 potential reconstructive needs were identified in 157 patients, an average of 2.2 per patient.
The anatomic region with the highest number of reconstructive needs was the head and neck in adults 25 (42%) and the upper extremity 51 (52%) in children. The trunk and lower extremity accounted for the least reconstructive needs in adults 12 (20%). In children the least reconstructive need was found in the head and neck region 17 (18%) [Table 1]. When the reconstructive needs were stratified by anatomic units in the head and neck, the upper eyelids 8 (32%) and the neck 6 (24%) had the highest frequency of reconstructive needs in adults. The upper eyelid, mouth and neck accounted for 13 (76%) of the reconstructive needs in children [Table 2]. The axilla was the most common anatomic unit in the upper limb requiring reconstruction in adults 8 (35%). In children, the most common reconstructive needs were identified in the hand 21 (41%) followed by the wrist 13 (25%) and the elbow 10 (20%) [Table 3]. In the lower extremity, the anatomic unit with the highest frequency of reconstructive needs in both adults and children was the ankle and foot 23 (56%) [Table 4]. There was only 1 (8%) reconstructive need in the perineum and hip and thigh anatomic units in adults.
|Table 1: Summary of reconstructive needs by anatomic region in adults and children |
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|Table 2: Distribution of reconstructive needs in the head and neck in adults and children |
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|Table 3: Distribution of reconstructive needs in the upper limb in adults and children |
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|Table 4: Distribution of reconstructive needs in the trunk and lower extremity in adults and children |
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Seventy-eight (50%) of the 157 patients had at least two contractures. Twenty-two (14%) had three contractures, and only eight had more than four contractures (5%) [Table 5].
| Discussion|| |
One of the major impediments to the successful rehabilitation of the burn victim is the development of contractures. , As burn survival rates have increased significantly in the past few decades, the incidence of contractures has also increased. The incidence of contractures in the pediatric population has been shown to be more prevalent, and accounted for up to 50% of all burn complications in several studies. ,, The findings in this study that children had more reconstructive needs is in keeping with these reports. An earlier study from Nigeria also found that 58% of the 76 patients with contractures were children aged 0 to 15 years.  These findings are similar to those of Forjuoh et al.,  in Ashanti Region, which showed a high prevalence (17.4%) of physical impairments from childhood burns in children aged 5 years or younger. The study of Fuojoh, et al. identified a link between maternal education and childhood morbidity from burns, and recommended enhancement of female access to formal education to reduce burn-related physical impairments. Possibly, this factor has not improved over the years.  Poor compliance with splinting and exercise programs may have contributed to the high incidence of contractures in children.  Dewey, et al.  posited that young children have not developed the cognitive reasoning to fully comprehend the benefits of such interventions, which leads to increased anxiety and decreased cooperation. Furthermore, a child's small body size, increased activity level, and decreased attention span create challenges with fabrication, fit, and compliance of positioning and splinting devices. Children are physically and emotionally dependent on a larger family unit, so all treatments must incorporate parents, caregivers, or other family members for a successful outcome. 
In this study the hand was the most common anatomic unit requiring surgical interventions in children. This is consistent with the results of other studies. In the series by Kalaja, 50% of the reconstructive procedures were on the hand.  Dobbs and Curreri  retrospectively reviewed 681 patients and found that 28% developed contractures. The hand, elbow, and shoulder were the most frequently affected joints. Similarly, a retrospective review of burn contractures by Kraemer  found that the hand and axilla were the most frequently affected joints. It is not surprising that the upper extremity is the most common anatomic region with potential reconstructive needs. First, it is the most common part of the body area burned in our patient population, and, secondly, it is a functionally important body area.  The functionality of the upper limb is dependent on adequate movement at all joints from the axilla to the finger tips, and adequate shoulder motion is required to strategically position the hand to facilitate its functions.  Although there appears to be conflict regarding the timing of these reconstructive procedures (early versus late), with decisions somewhat dependent on the individual burn center's protocol, it seems that there is a clear need to document the presentation of contractures adequately to provide consistent information for reconstruction and rehabilitation. ,,,,,,
The head and neck is the most common anatomic region with reconstructive needs in adults in this study. The face is more likely to be reconstructed due to aesthetic and functional reasons.  This is because any deformity of the face has always been considered as one of the least desirable handicaps. , Postburn contractures in the head and neck region in children present with the same challenges seen in adults, with additional developmental and psychologic concerns.  Facial form is characterized by convex and concave surfaces in juxtaposition, highly varied skin thickness, undulating and isolated hair-bearing areas, and structures lacking internal support. These characteristics facilitate the multiple dynamic subunits essential for sight, speech, and feeding.  The eyelids, mouth and nose are thus difficult areas to maintain in a functionally competent as well as cosmetically acceptable manner with the currently available compressive and positioning devices. , The higher incidence of contractures in the head and neck regions in adults may have been related to the difficulty in maintaining splints and positioning in these central body regions, in contrast to the peripheral extremity. 
In this study 26%(41) of the total reconstructive needs were in the trunk and lower extremity. This is similar to the report by Brou, et al.,  where 27% of the potential reconstructive needs in 25 patients who survived severe burns were in the torso and lower extremities. While isolated burns of the feet are not common, involvement of the feet in large surface area burn where the lower extremity has been affected is fairly common. Attention to life-threatening issues as well as pre-occupation with the need to cover priority areas such as the face and hands make burn scar contractures of the foot a common occurrence.  Other factors include prolonged immobilization and inadequate skin coverage. In addition, poor compliance with post-acute physical therapy programs aimed at minimizing scar hypertrophy and contractures may play a significant role.  Post-burn scar contracture is a common cause of stiff foot and ankle joints. Deformed foot contour and stiffness of the toe and ankle joints are sources of morbidity leading to gait disturbances, growth abnormalities, improper shoe fit and recurrent ulcerations. ,
The management of post-burn contractures is complicated by the frequent occurrence of multiple reconstructive needs.  In this study 40 patients (25%) had three or more contractures. When contractures are multiple, especially in severe burn injuries, donor tissue is severely limited and that which is available may be of poor quality.  An inventory of potential reconstructive needs is imperative in the comprehensive planning of reconstructive procedures in these patients. Finally, a patient, parent, surgeon priority survey is made to match desires with feasibilities. 
| Implications for clinical care and research|| |
Post-burn contractures are debilitating but potentially preventable. Previous studies have demonstrated that burn wound excision and the application of split-thickness skin grafts can significantly reduce contracture formation. ,, To minimize further joint immobility and maintain tissue length in healing wounds, an approach consisting of both grafting and splinting techniques is recommended. Collectively, these studies suggest that complete initial treatment of burn wounds may significantly decrease subsequent contracture formation and help form the justification for current standards of burn care.  A knowledge of the frequency and distribution of contractures will be helpful in planning resource allocation for the treatment of hospitalized burn patients and predicting outpatient needs of burn survivors as it applies to contracture management. Likewise, such information is useful to insurance companies, enabling them to better plan for costs related to future therapy and surgical care related to contracture management. 
Furthermore, this presents a challenge to the burn team to find new and better ways of preventing contractures. Future studies may investigate the efficacy of outpatient physical and occupational therapy in improving the outcome of contracture management. Investigators may also examine the correlation between contractures and return to work outcomes.
| Conclusion|| |
We found that there were more children with reconstructive needs than adults in the population studied. The anatomic region with the highest number of reconstructive needs was the head and neck in adults and the upper extremity in children. A quarter of the patients in this study had three or more contractures. Given the frequency of contractures and having considered the multiple factors contributing to contracture development, this study underscores the importance of positioning, intensive therapy and appropriate surgical intervention in the hospitalized burn patients.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]