Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 11  |  Issue : 1  |  Page : 19-22

Post burn digital contracture our way: The pains, The gains


1 Department of Surgery, Federal Teaching Hospital, Gombe, Nigeria
2 Department of Radiation Oncology, Federal Teaching Hospital, Gombe, Nigeria

Date of Web Publication8-Oct-2015

Correspondence Address:
Zainab Yunusa Kaltungo
Department of Surgery, Federal Teaching Hospital, Gombe
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0794-9316.166848

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  Abstract 

Background: Post burn digital contractures account for 30% of new outpatient clinic visits but 25% of elective surgery load in our practice. There is a lot of backlog and pressure to operate particularly in the pediatric age group. We were able to demonstrate in this series that irrespective of the duration, uncomplicated post burn contractures are usually not complicated by ankylosis and a single stage complete release is possible.
Aims and Objectives: 1. To determine if multiplicity of joint involvement and duration between burn and corrective surgery affect outcome. 2. To determine the range of complications after post burn digital contracture release. 3. To determine if preoperative plain radiographs are necessary in uncomplicated post burn digital contractures.
Materials and Methods: Retrospective analysis of the records of 33 patients. Data collected included socio demographic and disease characteristics, etiology of burns, duration of burns before corrective surgery, complications after corrective surgery. Data was analyzed using SPSS version 16.0. All patients with contractures in other joint other than digits and from other causes other than burns, or burns associated with mechanical trauma were excluded.
Results: Mean age 8 yrs, nearly equal sex distribution. Scald 48.5%, flame 21.2%, contact burn 9.1%, others 21.2%. Mean duration between burn and contracture release 40months. Overall, 172 joints were involved in 33 patients, 69.7% had incision ,+ FTSG, 3% had incision+ STSG, 6.1% had Z plasty only and 21.2% had Z plasty + FTSG. In 32 patients (97%) complete intra op contracture release was achieved. Twenty patients (60.6%) healed without complications, recorded complications post op were wound infection (30%), graft shift and digital tip gangrence.
Conclusion: Prolonged duration between burn and eventual contracture release does not affect achieving complete contracture release, neither does multiplicity of joint involvement.

Keywords: Full-thickness skin graft, postburn contractors, split-thickness skin graft


How to cite this article:
Kaltungo ZY, Bojude AD, Olajide OS. Post burn digital contracture our way: The pains, The gains. Nigerian J Plast Surg 2015;11:19-22

How to cite this URL:
Kaltungo ZY, Bojude AD, Olajide OS. Post burn digital contracture our way: The pains, The gains. Nigerian J Plast Surg [serial online] 2015 [cited 2019 Aug 19];11:19-22. Available from: http://www.njps.org/text.asp?2015/11/1/19/166848


  Introduction Top


Perhaps the reason patients/caregivers seek correction of postburn digital contractures is due to the way they hinder practically all activities of daily living.[1],[2],[3] On the part of the surgeon in the developing world, there is the ever present pressure of the long waiting list, limited window of access to routine surgery [3],[4] and the psychological trauma of knowing that the quality of outcome decreases with passing time.[2],[5] The situation is worsened when the patient is a child, still developing a hand pattern, and when multiple joints are involved in a dominant hand. We set out to study the effects of multiplicity of joint involvement and the duration of contracture on the extent of contracture release and the pattern of postoperative complications in this group of patients.


  Materials and Methods Top


A retrospective analysis of the hospital records of 33 patients with postburn contractures involving 172 joints was carried out. The patients were all operated on at the Federal Teaching Hospital (formerly Federal Medical Center) Gombe, Gombe State, Nigeria between November 2007 and February 2013. All patients with digital contractures from any other cause alone or in combination with burns were excluded. No patient in the study group had preoperative radiographs of the affected hand. Mobility of the joint was tested clinically and was judged as affected if there was a slightest reduction in range of motion (ROM). According to the classification of Stern et al.,[6] the contractures in our series are divided into grades II and III. All the patients in our series but one were recruited from the outpatient clinic. The exception, was managed from the acute stage in our facility. The contractures were released via Z-plasty where there exist bridle scars, and via incision and skin grafting where the angle of contracture was tight (in most of such cases, the contracture presented as a near-clenched fist), or a combination of Z-plasty and skin grafting was done in those where the pattern of contracture varied between different digits. In all patients, complete contracture release was achieved and maintained with intraosseus k-wires or the stylet of intravenous cannula was passed from the distal phalanx to the metacarpophalangeal(MCP)joint. Plaster of Paris (POP) was used to augment immobilization where the angle of contracture was severe [7] or the contracture had been for more than 1 year. Graft immobilization was with tie-over dressing using 2-0 silk. Postoperatively, the hands were elevated on pillows and with collar and cuff when the patient started to ambulate. The wounds are routinely inspected on 10th postoperative day except where a wound infection is suspected. In such cases the patient is put on daily dressings until infection is cleared. Daily wound dressings were done until all evidence of infection was cleared or wound dressing was done twice weekly if there was no wound infection. The POP was discarded after the first wound inspection but the k-wire or stylet splints were retained for 3 weeks. The patients were discharged once the wound was adjudged to have healed sufficiently to be managed with topical antimicrobial cream.

At the removal of k-wire/stylet, active and passive ROM physiotherapy was commenced and the patient followed up in the outpatient clinic fortnightly or monthly depending on the nature of the wound. The patient was said to have full ROM if he/she could fully flex the involved joints into the palm and extend the digits to an angle of 180° to the horizontal.

All patients were lost to follow-up by 6 months but all wounds had healed at the last documented follow-up visit. This problem appears to be common in publications from developing countries.


  Results Top


Among the 33 cases, the results of whose records were analyzed, 85% were in the pediatric age group. The median age was 5 years (standard deviation 7.78 years) [Figure 1]. There were 19 males 57.6% and 14 females (42.4%). In total, 172 joints were involved with the proximal interphalangeal (PIP) joint being the most frequently involved, with a frequency of 93 followed by the distal interphalangeal (DIP) joint with 42 and MCP with 37 joints involved. Regarding the etiology of burn injuries, scald accounted for 16 (48.5%) cases, flame 7 (21.2%) cases, and contact burn occurred in 3 (9.1%) cases and others including chemical, electrical burns were a cumulative 7 (21.2%) cases [Figure 2].
Figure 1: Histogram of age and frequency distribution

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Figure 2: Distribution of burn etiology

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Mean duration between acute burn and contracture release surgery was 40 months (range: 1 month to 16 years). Six patients had had a previous attempt at contracture release before referral to our facility. Analysis of the methods of contracture release showed that 23 (69.7%) patients had incision + full-thickness skin graft (FTSG), 1 patient (3%) had incision + split-thickness skin graft (STSG), 2 (6.1%) had Z-plasty only while 7 (21.2%) patients had a combination of Z-plasty and FTSG. Complete contracture release was achieved in all but one of the 33 patients (97%). A total of 172 joints were involved, out of which MCP joint accounted for 37, PIP joint 93, and DIP joint 42, making PIP joint the most frequently involved joint. In the postoperative period, complications encountered include wound infection in 10 patients (30.3%), graft shift in 1 patient (3%), and digital tip gangrene in 2 patients (6%); 20 patients (60.6%) had no documented complications. A high incidence of patients were lost to follow-up, depriving us of documentation on long-term follow-up.


  Discussion Top


Analysis of the demographic distribution of the patients revealed a near-equal gender distribution; most patients were in the pediatric age group and this was consistent with the findings of several authors.[2],[8],[9] At recruitment in the outpatient clinic, clinical examination finding of the slightest motion in the joint was taken to mean no ankylosis and no routine radiograph was done (first rule broken) to rule out the same. No bony ankylosis was encountered in any of the patients intraoperatively and this is evidenced by complete contracture release achieved in all but one patient. Conventional wisdom in contracture release advocates that the proximal joint is released before the distal [4],[10] but our practice is to release all contractures in continuity (second rule broken) by incising perpendicular to the scar while applying maximum stretch on the scar. Where the contracture has been longstanding, difficulty is encountered overcoming the elastic recoil of the digit or there is associated dense fibrosis and the scar is incised as described above while a stretch-release cyclical manoeuver is done. This involves stretching the digit until resistance is encountered, releasing the digit to the contracted position and stretching again. Each phase of the cycle is maintained for about 15 s and at subsequent cycles, the stretch is only slightly extended beyond the preceding one. This manoeuver is continued until the resistance is overcome and the digit maintains the stretched position at rest. The nail bed of the digit is checked for capillary refill during each phase of the cycle. The aim of this stretch-release cycle is to gradually break the scar and stretch/lengthen the tendon and neurovascular bundle without causing vascular intimal tear or neural damage. We found this to be the only way to achieve a complete contracture release intraoperatively. This is a particularly time-consuming process but when the long surgery waiting list and cost of several staged surgeries are considered, this option gets the nod. Where multiple joints are involved, a decision as to the method of release and choice of cover for the secondary defect is made in the following manner: If the contracture is severe [11] and multiple, it are released by incision + FTSG. Several studies have shown the benefit of FTSG over the STSG [10],[12],[13] in resurfacing the defect created by digital contracture release or burn wound excision;[14],[15] hence, the choice of FTSG in a majority of our patients. The decision to use STSG instead of FTSG comes in when the contracture is mild,[11] limited to a single joint, and there is robust unaffected surrounding skin. If a long bridle scar is present with adjacent normal skin, the contracture is released via Z-plasty. Z-plasty is combined with FTSG in patients where there is a mixed pattern of digital involvement. Such patients have suitable bridle scars in some digits and severe contractures in the other digits.[13] The choice of splint used to maintain contracture release was dictated by availability. Half millimeter k-wire is preferred in the very young to minimize trauma to the growth plate and articular cartilage, 1 mm k-wire is used if the patient is older than 17 years of age. Where not available, the stylet of intravenous cannula was used. Plaster of Paris (POP) back slab or full cast was used to augment the immobilization until first wound review. Complete contracture release was achieved in all but one patient. There was no documentation in the notes of the patients with incomplete contracture release as to the reason why the release took place.

In our series, wound infection was the most frequently documented complication occurring in 10 (30.3%) patients. All wound infections were treated with wound dressings only; no systemic antibiotics were used and no infection resulted in graft loss requiring more than conservative management. One patient had graft shift exposing about 20% of the grafted defect and this resolved with meticulous wound care to prevent infection while the graft was spreading. Of the two (6.1%) patients with digital gangrene, one had dry gangrene up to the DIP and the second had what was initially thought to be gangrene of the skin of the distal pulp that healed with no deformity. On further review, it was concluded that this second case might not have been gangrene but hematoma of the pulp of the finger (during k-wire fixation) that organized and resolved. This opinion was reinforced by the fact that no sloughing or deformity resulted even as the patient was managed conservatively. Further probe into the case of the patient with complete digital tip gangrene revealed that the patient did not have the stretch-release maneuver intraoperatively despite having a longstanding (>10 years) contracture. This necessitated the unit adopting the maneuver in subsequent patients who met the criteria. This brings the incidence of complications encountered in our series to 39.4%. The complication rate was higher than what was recorded by Tucker [3] even though the spectrum of complications was quite different.

The major challenge that we encountered in our practice was the loss of patients to follow-up that was also documented by Tucker.[3]

This problem means that we cannot assess recurrences, reduction or maintenance of achieved ROM, pigmentary, and other previously published complications of contracture release.


  Conclusion/recommendations Top


In otherwise uncomplicated postburn contractures involving the digits irrespective of the duration and the number of joints involved, it is possible to achieve complete contracture release by releasing skin cicatrix if the sole cause of the contracture is a burn injury.

Also, in this group of patients, a clinical assessment of joint mobility may be enough, without a need for preoperative radiographs to rule out bony ankylosis of the underlying joint. However, long-term follow-up will be required to assess the effect of reconstructive surgeries in these patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Davies D. Plastic and reconstructive surgery. The hand-I. Br Med J (Clin Res Ed) 1985;290:1650-3.  Back to cited text no. 1
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2.
Ayub A, Khundkar SH. Outcome of skin graft in post burn finger contractures: An integrated technique of evaluation. J Bangladesh Coll Phys Surg 2009;27:25-9.  Back to cited text no. 2
    
3.
Tucker SC. Reconstruction of severe hand contractures: An illustrative series. Indina J Plast Surg 2011;44:59-67.  Back to cited text no. 3
    
4.
Gökalan L, Özgür F, Gürsu G, Keçik A. Factors affecting results in thermal hand burns. Annals of Burns and Fire Disasters 1996;9:222-8.  Back to cited text no. 4
    
5.
Robson MC, Smith DJ Jr, VanderZee AJ, Roberts L. Making the burned hand functional. Clin Plast Surg 1992;29:663-71.  Back to cited text no. 5
    
6.
Stern PJ, Neale HW, Graham TJ, Warden GD. Classification and treatment of post burn proximal interphalangeal joint flexion contractures in children. J Hand Surg Am 1987;12;450-7.  Back to cited text no. 6
    
7.
Iwuagwu FC, Wilson D, Bailie F. The use of skin graft in post burn contracture release: A 10-year review. Plast Reconstr Surg 1999;103:1198-204.  Back to cited text no. 7
    
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Iregbulem LM. Postburn volar digital contractures in Nigerians. Hand 1980;12:54-61.  Back to cited text no. 8
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9.
Kraemer MD, Jones T, Deitch EA. Burn Contractures: Incidence, predisposing factors and results of surgical therapy. J Burn Care Rehabil 1988;9:261-5.  Back to cited text no. 9
    
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Hudson DA, Renshaw A. An algorithm for the release of burn contractures of the extremities. Burns 2006;32:663-8.  Back to cited text no. 10
    
11.
Strickland JW. Flexor tendon injuries. Part 1. Anatomy, physiology, biomechanics, healing, and adhesion formation around a repaired tendon. Orthoop Rev 1986;15:632-45.  Back to cited text no. 11
    
12.
Gulgonen A, Ozer K. The correction of postburn contractures of the second through forth web spaces. J Hand Surg Am 2007;32:556-64.  Back to cited text no. 12
    
13.
Schwarz RJ. Management of postburn contractures of the upper extremity. J Burn Care Res 2007;28:212-9.  Back to cited text no. 13
    
14.
Pensler JM, Steward R, Lewis SR, Herndir DN. Reconstruction of the burned palm: Full thickness versus split thickness skin graft – long term follow-up. Plast Reconstr Surg 1988;81:46-9.  Back to cited text no. 14
    
15.
Park YS, Lee JW, Huh GY, Koh JH, Seo DK, Choi JK, et al. Algorithm for primary full thickness skin grafting in paediatric hand Burns. Arch Plast Surg 2012;39:483-8.  Back to cited text no. 15
    


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