|Year : 2020 | Volume
| Issue : 1 | Page : 18-23
Post burn perineal contractures: case series and a classification system
Rex Ochuko Dafiewhare1, Ifeanyi Igwilo Onah2
1 Department of Surgery, Wuse District Hospital, Abuja, FCT, Nigeria
2 Department of Plastic Surgery, National Orthopaedic Hospital Enugu, Enugu State, Nigeria
|Date of Submission||01-Aug-2019|
|Date of Acceptance||29-Jun-2020|
|Date of Web Publication||17-Sep-2020|
Dr. Rex Ochuko Dafiewhare
Wuse District Hospital, 10 Conakry Street, Abuja, FCT
Source of Support: None, Conflict of Interest: None
Introduction: Perineal burn contractures remain under reported in our region. We have set out to study the pattern of presentation, describe the formation of these contractures and identify any recurring patterns that will form a basis for a classification that will be useful in planning their management. Methods: A retrospective study of the patients seen over a three year period (2009–2011) at the National Orthopaedic hospital Dala is presented. Information was retrieved from case notes in the medical records department. The bio-data, type of care received post injury associated percentage burns, formation of contractures, were all noted. Results: All the seven patients seen were children of which five were females. Flame burn was the main type of burn. All burns occurred at home. Four major types of contractures were identified as transverse bands, hooding, fusion and obliteration. An equal number of patients presented following home versus hospital care. Conclusion: The relative rarity of post burn perineal contractures leaves little experience for the young surgeon to take advantage of when in training. A classification system will help to make it easier to identify what structures are involved and make planning easier. In the absence of specialized care it is doubtful that there is any statistical difference in the likelihood of perineal contracture development of patients managed at home by traditional healers versus those presenting in peripheral centers lacking formal burn management protocols. Most childhood burns still occur at home. There is a need to continually educate the public on the need to make the home a safe place for children.
Keywords: burns, perineal burns, perineal contracture, post burn contracture
|How to cite this article:|
Dafiewhare RO, Onah II. Post burn perineal contractures: case series and a classification system. Nigerian J Plast Surg 2020;16:18-23
|How to cite this URL:|
Dafiewhare RO, Onah II. Post burn perineal contractures: case series and a classification system. Nigerian J Plast Surg [serial online] 2020 [cited 2021 Jun 23];16:18-23. Available from: https://www.njps.org/text.asp?2020/16/1/18/295254
| Introduction|| |
The perineum is that part of the body inferior to the pelvic diaphragm and between the thighs. For practical purposes, the superficial borders will include the anus and inferior gluteal fold posteriorly, the medial aspect of the thigh laterally and up to the Mons pubis or its equivalent in the male anteriorly. Perineal burns are known to be relatively uncommon[. The anatomical location of the perineum and the use of underpants may both confer protection from burn injury. Once burned however, contractures may develop easily. The technicalities of providing adequate dressing and splinting may be both uncomfortable and potentially embarrassing to the patient and care givers in a conservative society as ours. This may further impact negatively on the outcome of such injuries. Perineal burns are often associated with severe injuries. The deeper these injuries are, the more likely they will heal with contractures. The unconscious negligence of these wounds in a bid to fight for survival first and correct deformities later will surreptitiously lead to these contractures occurring. It could therefore be said that though perineal burn injuries are rare, when they occur, the chances of contractures developing are relatively high.
Burns limited to just the perineum especially in children should raise a suspicion of child abuse. Isolated perineal burns have also been known to occur with the use of sitz baths in children. The pattern of these contractures as seen in our clinic is presented. An attempt is made to classify these injuries based on the disposition of the contractures as it affects surgical options. Other workers have classified these contractures broadly as primary and secondary or (a) transverse scar folds formed between both the thighs and (b) obliteration of perineum by scar tissues. A classification based on our observation of these contractures is proposed.
| Materials and methods|| |
170 patients presented with post burn contracture in the outpatient clinic of the department of Plastic and Reconstructive surgery, National orthopaedic hospital Dala Kano between 2009 and 2011. 7 of these patients presented with perineal burn contractures. The bio data, causative agent and location of the burns were noted. Percentage burns associated with the contractures was determined by estimating the area covered by healed burn skin (except for one where the record of burn surface area was not recorded). The patterns of the contractures were noted and classified based on the relationship to the external perineal structures. Additional photographs have been added from case reports earlier published by the authors from a different health facility to illustrate type 2.
| Results|| |
7 out of 170 patients with post burn contractures representing 4.1% presented with perineal contractures in the 3 years under study. Male to female ratio was 1:2.5 (or 71.4% were females). The age at the time of injury had a range of 2-10 years with a mean of 6.5 years. The time between burns and first presentation with contractures was 6months to 1 year. Mean time was 10 months. All burns occurred at home. All injuries were caused by flame except for the 2 year old that fell into hot charcoal kept for warming the room. 5 of the patients (71.4%) were treated by traditional herbal methods at home. The other 2(28.6%) were initially managed in peripheral hospitals that did not have a burns unit. Four (66.6%) out six patients were able to afford and had surgery within the period of study, all surgeries were managed by one or a combination of scar excision, local flaps and split skin grafting.
| Classification|| |
Transverse band: Contracture bands run from one or both thighs or groins to the perineum exerting a pull on the structures. The genitals and /or anus are still visible but distorted in alignment
- 1a. Unilateral bands
- 1b. Bilateral bands
Hooding: Broad transverse contracture across the perineum involving both thighs and extending distally beyond the Mons pubis (or its male equivalent). The genitals or anus may be attached to the contracture but still separable from it.
- 2a: Anterior hooding. Perineum visible only in lithotomy position
- 2b Anterior and posterior hooding. Perineum may be visible through a hole. Effluents dribble through singular or multiple openings. Coitus may be impracticable.
Fusion: the genitals or anus is scared with fusion of labia, scrotum and penis or anal verge with the buttocks. Various degrees of obstruction of effluents may result
Obliteration: The perineum is deeply charred and reconstruction of neo structures has to be embarked upon. This type may only be seen in deliberate assault, altered state of consciousness. This may be a largely theoretical type.
Goals of management
The goals are full range of thigh movement and centrally placed functional genitalia, urethral meatus and anal opening which are aesthetically acceptable to the index patient.
These goals are more easily achieved with Type 1 while Type 4 has the greatest likelihood of failure.
| Discussion|| |
Perineal burns continually to be recorded as rare burns as in various studies,. Pisarski et al. (0.34%) had very low figures. 4.1% of our patients presenting with contractures in this period is a much higher figure. This may be accounted for by the selective referral of complex cases to our unit as it was the only plastic surgery unit serving the state and environs of over 18 million people. All our patients were children. Thakur et al. similarly had only children in his series. The inability of children to take off clothing or call for help may account for this. Adults have thicker skin than children and therefore are less likely to develop full thickness burns. They are also more likely than children to wear underpants. Also, the difficulty of managing perineal burns may be further increased when children who are by nature less cooperative are the victims making them more likely to develop contractures. Female children in our locality are co-opted into domestic chores at an earlier age than males. This may account for their higher numbers sustaining burns at home from use of firewood in the kitchen. Severe burns commonly occur in this geographical region from long flowing flammable cotton clothing traditionally worn especially by females. Patients managed at home by traditional healers are more likely to develop complications than those in peripheral health centers even in the absence of specialists. Burn units exist only in large government hospitals mostly managed by general practitioners. The sheer nature of the anatomy of this region makes it very difficult to avoid post burn sequelae except in the hands of well trained and equipped personnel. Patient’s presentation is adjudged relatively early in our practice. Presenting at a mean of 10 months post injury, the contractures have likely just set in. Parent anxiety about the unyielding scars in this “sacred” area may be responsible for seeking help early.
Thakur et al. have described perineal contractures and classified them as 1. Primary in which the perineum including genital organs and anus were directly burned. 2. Secondary in which surrounding tissue were burned and scars pulled on the perineum. Grishkevich observed two main formations (a) transverse scar folds formed between both the thighs and (b) obliteration of perineum by scar tissues. These observations while being very apt and simple remain very broad and may not reflect fully the differences in the severity of these contractures and hence the expected tissue loss that will have to be replaced or reconstructed in the management of these contractures. We have further divided these formations to further express the various patterns that these contractures may adopt and likely mode of treatment.
Type 1(Transverse bands) Contractures may be easily amenable to the use of multiple local transposition flaps utilizing post burn skin where possible (fig). Otherwise excision with the use of skin grafts will suffice.
Type 2(Hooding) contractures are more extensive. The use of flaps from surrounding normal tissue may be required in addition to the use of post burn skin. Pisarski et al. have alluded to the superiority of flaps over skin grafting in terms of simplicity of overall aftercare. Diversion of effluents with catheters or the use of colostomies may be required in the immediate post operative period.
Type 3(Fusion) and 4(obliteration) contractures may present in addition with inability to achieve coitus, and intestinal obstruction.,
Various techniques to maintain splinting and tie over grafts will be required. Aesthetic concerns may also warrant more revision surgeries than other types. Ancillary surgeries like colostomies for faecal diversion may be required in types 3 and 4 contractures.[Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7],[Figure 8],[Figure 9],[Figure 10],[Figure 11]
|Figure 8 Type 2a lithotomy position. Genitals are visible in this position|
Click here to view
Type 4 contractures require full reconstruction of neo structures after excision of deeply scarred and disfigured remnants of perineal tissue. Regional or free flaps will be required.
| Conclusion|| |
Post burn perineal contractures are relatively rare. Non familiarity with these contractures may cause the young surgeon to shy away from these contractures when confronted with them. A careful analysis of the formation will make for easier planning and execution using basic principles of contracture release. The high percentage of children involved again brings to mind the need to make the home (where most childhood burns occur) a much safer place for children.
Many thanks to Joshua Orowowho for his encouraging words, Betty Dafiewhare for an enabling environment to work.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]