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. 2021 Jun 30;34(2):192–198.

Algorithms For Management Of Post-Burn Contracture In Upper Extremity In Children

H Terziqi 1,2,3, I Sopjani 3, B Gjikolli 3,4, G Muqaj 2, M Mustafa 3,∗
PMCID: PMC8396151  PMID: 34584510

Summary

The aim of this study is to describe the management and outcome of surgical treatment for post burn contractures in different parts of the upper extremities in children, and provide a final decision algorithm that can be a useful guide for the Resident regarding surgical approach to contracture management. This was a retrospective study conducted in the Clinic of Plastic and Reconstructive Surgery, Pristina-Kosovo, between 2014-2016. All cases continued check ups in the Gentiana-Grelor private clinic in Pristina until 2019. Followups were conducted for no less than 6 months with respect to the viability and healing of the repaired area. Patients of both genders, aged from 0 months to 18 years with post-burn contracture in upper extremity, were included in the study. For the sake of presentation, we divided them anatomically into four main areas: axilla, elbow, wrist and hand. We start with a reconstructive ladder using skin grafts (STSG, FTSG), and local flaps such as advancement flaps, Z-plasties, V-Y or Y-V advancement flap, abdonimal/groin pedicled flap, cross finger flap, radial forearm flap were used. Patients were called for follow-up lasting a minimum of one to up to three years. The study included 144 patients. Their age ranged from 9 months to 18 years, the mean age being 12 years. Ordering them by location, post-burn contracture percentage in upper extremity in children was 68% on the hands, 18% on the elbows, 8% on the axilla and 6% on the wrist. A classification and treatment algorithm aids in achieving significant improvements in both joint motions and aesthetic deformities.

Keywords: algorithm, surgical technique, contracture, axilla, elbow, wrist, hand, children

Introduction

Burns are the fourth most common accidental injury causing death in children. Burns are also the primary cause of accidental death in children younger than 2, and the second cause of death for children younger than 4. The most common type of childhood burn is a scald injury, which accounts for 72% of pediatric burns. Post-burn contractures are distressingly common and severe in developing nations and are a significant problem in developed countries as well. Many patients still suffer from the disabilities caused by burns, especially after suboptimal primary care or major burns.

The aim of this study is to define the complexity of surgical treatment of post burn contracture in upper extremity in children admitted to the Clinic of Plastic Surgery, University Clinic Center Pristina- Kosovo, between 2014-2016. After the surgical treatment the patients were called for follow ups until 2019.

Beneficial algorithms have been invented which are used to assist reconstructive surgeons in selecting appropriate reconstructive methods following release of burn scar contractures. These algorithms are an attempt to simplify the approach to burn contracture reconstruction. Advantages and disadvantages of these different modalities should be considered and compared before deciding to go forward with the treatment. An algorithm for surgical treatment in post-burn contracture in upper extremity in children is proposed.

Materials and methods

A total of 144 patients were included in our study on post-burn scar and contracture in upper extremity and without metabolic derangements. The study includes patients from the age of 9 months up to 18 years, with a mean age of 12 years. It includes both sexes: 71 males (49.3%) and 73 females (50.7%). Nine patients (6.25%) had previous surgery and 135 patients (93.75%) underwent no operation. During assessment, x-rays were done to see if the joint was also involved in the contracture or not. All patients were assessed clinically for site and type of contracture, restriction in range of motion, and classified as follows: axilla according to Kurtzman and Stern’s classification, elbow joint PBC were classified depending on loss of joint extension, and the hands according to McCauley into four severity grades. All cases continued their follow up in the Gentiana-Grelor outpatient clinic in Pristina, Kosovo. Followup was conducted for no less than 6 months with respect to the viability and healing of the repaired area. Physiotherapy was considered in the management of cases postoperatively, tailored to each case.

Given that most of the children were from poor families (with low health education) and from rural areas of Kosovo, we considered that these children would have limited opportunities to conduct exercises or be treated with compression garments (which the family needed to buy themselves). Thus we asked the families to attend medical visits every 6 months, which would then enable us to observe the children’s progress for up to three years.

Exclusion criteria were children with contractures who had been treated without a surgical intervention, such as with compressive garnments, silicon sheets, ointments etc., patients with post-burn syndactily, and patients with severe disease comorbidities or with infection of the upper affected limb. Post-burn scars (keloid and hypertrophic) were not included in this study due to there being a small number of patients suffering from post-burn scars in combination with contractures.

Results

Specific regions with contracture in upper extremity were evaluated seperately. The study found that axillary contractures were present in 11 cases (7.63%), elbow contracture in 26 cases (18.05%), wrist contracture in 9 cases (6.25%) and contracture in the hand in 98 cases (68%), of which 89 (61.8%) were phalangeal finger flexion contractures and 9 (6.25%) were dorsal extension contractures.

Demographic details of patients with contracture included in the study were as follows:

  • Number of patients 144 of both genders, female:male ratio 73:71 (1.03: 1)

  • Age range: 9 months-18 years, mean age 12 years

  • The most affected age group • was 9 months-5 years (3 years)

  • Axilary contracture 11 (7.63%) (Tables I-II, Fig.1)

  • Elbow contracture 26 (18.05%) (Tables III-IV, Fig. 2)

  • Wrist contracture 9 (6.25%) (Table V, Fig. 3)

  • Hand contracture 98 (68.05%), of which 89 (61.80%) were flexion and 9 (6.25%) extension (Tables VI-VIII, Figs. 4-6)

  • 166 surgical procedures were performed in 144 patients for an average of 1.14 procedures per patient

  • Patients with more than one or two contractures, treated in one operation with two different methods = 22 (15.27%)

  • Patients who had had operations before, after a major burn injury (treated in our clinic) = 9 (6.25%)

  • Patients undergoing first operation = 136 (93.75%)

  • Patient with splints after surgery = 75 (52.08%)

  • Patients without splinting = 69 (47.92%)

  • In the year 2013, 34 patients presented, 23.61% of all patients

  • Hospital stay from 1 day-7 days (mean 11days)

Table I. Reconstructive surgery used for axillary contracture release.

Table I

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Table II. Distribution of axilla contracture release according to Kurtzman and Stern’s classification.

Table II

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Fig. 1. Algorithm of PBC axilla (Kurtzman and Stern classification).

Fig. 1

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Table III. Elbow joint PBC were classified depending on loss of joint extension.

Table III

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Table IV. Surgical procedures we performed to release elbow contracture.

Table IV

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Fig. 2. Algorithm of surgical treatment of elbow contracture.

Fig. 2

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Table V. Different procedures performed to release wrist contracture.

Table V

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Fig. 3. Algorithm of surgical treatment of wrist contracture.

Fig. 3

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Table VI. Classification of burn contractures based on McCauley’s severity grade.

Table VI

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Table VII. Different surgical methods used to release contracture in the palm of the hand.

Table VII

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Table VIII. Surgical methods for extensor contracture of the hand.

Table VIII

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Fig. 4. Algorithm of hand with palmar involvement.

Fig. 4

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Fig. 5. Algorithm in finger flexion contracture.

Fig. 5

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Fig. 6. Algorithm of hand with dorsal involvement with extension to digits.

Fig. 6

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Discussion

Demographic factors are: low socio-economic status of the family, and low educational level of the mother, which was an important factor in post burn medical care. The other demographic factors associated with a high risk of burn injury are: high population density, family with many children, and psychological stress within the family.

Re-construction of a post-burn contracture is a challenge for the surgeon, especially in cases where tendons, ligaments and joints are also involved in the contracture.1,2 A study conducted by S.C. Tucker shows that patients with severe post-burn contractures must be treated by a surgeon who has mastered a range of flaps within a setting where physiotherapy expertise is available. A study conducted by Ogwa et al. shows that free flaps have satisfactory results for axillary contracture, but size, shape, location and depth of contracture must be kept in mind for the selection of surgical method.3,4 Askar conducted a study and shows that double reverse V-Y flap is easy to use when tension across contracture line is too great to use any local flap. Young et al. show that maximum functional improvement is achieved in younger children as joints and tendons have laxity.5 The study also shows that local flaps have excellent outcomes; free tissue transfer is good in children and Integra artificial skin needs extensive post-operative care and is not easy to use. A study by Stern et al. shows that grafts, flaps and deep releases have equally good to excellent results regardless of the technique we use.6,7 Ignatidis et al. show that distal ulnar and radial artery perforator based flaps have good functional and aesthetic outcome, are easy to obtain and cover both dorsal and palmar defects without significant functional deficits or donor site complications.8

In our study we analyzed the various surgical methods and we used Kurtzman’s classification as our guide in management, as appropriate treatment for axillary contractures could be determined on the basis of this classification.9,10 Type 1A-injury involved anterior axilla fold A double Z-plasty with Y-V advancement being the procedure of choice. Type 1Binjury involved posterior axilla fold. A double incisional release on both sides of the hair-bearing area is the procedure of choice. Type 2-injury involved both anterior and posterior axillar fold (sparing axillary dome). The procedure of choice in these cases is a double incisional release. Type 3-injury involved both anterior and posterior axillar fold and axillary dome. This diffuse scar contracture is best treated by a single incisional release. Elbow joint PBC were classified depending on loss of joint extension.10 In negligible patients, when there is less than 10 degrees extension loss, for short and long length contracture we used diferent ‘Z’ plasty. Mild 11-49 degrees patients have mild loss of extension with long length contracture, where we used V-Y advancement flap, 5-flap plasty. In moderate, 50-89 degrees loss we used multi ‘Z’ plasty in combination with FTSG with satisfactory results. Severe, >90 degree loss was corrected with lateral arm fasciocutaneus flap with application of splint for two or three weeks.

We show that skin grafting for release of wrist contracture was the most effective surgical method, but we have good results with the groin flap.11,12 Pvalue presented with =0.907. In 9 (6.25%) patients with wrist contracture out of the total 144 patients we used skin graft (STSG, FTSG) in 3 (2.08%) patients, skin graft with local flap in 2 (1.38%), and radial artery perforator based on forearm flap and abdominal or groin flap in 2 (1.38%). We analyzed post-burn hand contractures based on McCauley’s severity grade. Subset classification for Grade III and Grade IV contractures: A - flexion contractures, B - extension contractures, C - combination of flexion and extension contracture. Grade I and II were managed with nonsurgical scar control measures and physiotherapy.12 The dorsum of the hand in children is not so often involved in burn injuries.

Our study shows that post-burn contracture is most common in hands as the hand is the commonest site to be affected by burns, as depicted by Gupta RK et al.13 We noted that in the hand, finger contractures are most common. Results clearly show that complications have no relation with the type of procedure we use and all types of technique have fair to excellent results.14,15 Size, shape, condition of joint and type of contracture are the important points to be kept in mind when deciding on the technique, because all the methods have comparable results. Development of contracture again after surgery is seen in three-four cases and upon investigation it was revealed that attendants and patient were negligent towards physiotherapy.16,17 Functional outcome of the surgery depends on the age of the patient and joint mobility and laxity. It is clear that maximum functional improvement is achieved in all cases in the age group from 9 months to 5 years. Even in the age group of 6 to 10 years the results are good, while in the age group 11-14, patients have limited range of movements but were able to complete their daily routine. In the 15-18 age group, there were a few patients with restricted movements and this is because of joint stiffness and loss of laxity in tendons and ligaments.18 It is also observed that maximum normal anatomical correction is obtained when the joint is not stiff or involved with the contracture. Patients underwent a physiotherapy course with a specialist as a routine part of each technique.19,20

Prolonged static splinting was required after skin grafting procedures, but therapeutic sessions were started within 2-3 weeks after surgery, removing the splint for each session. For different types of flaps, maintenance of released/corrected position was done until the flap margins had healed.21 The authors agreed that the most effective way of splinting scars is by surgical closure with intradermal sutures for at least 6 weeks and, when tension is substantial, for up to 6 months.

With this study we can say that competency in plastic surgery implies that a special combination of basic knowledge, surgical judgment, technical expertise, ethics and interpersonal skills are necessary in order to achieve satisfactory patient relationships and resolution. This evidence has implications for how we think about the impact of contractures on patient function. Activities of daily living, instrumental activities of daily living and occupational tasks are more affected in children with upper extremity impairments, thereby reinforcing the need for outpatient therapy after burn injury.22,23

Conclusion

Surgical intervention is aimed at obtaining good functional and aesthetic results and improving patient self-esteem. It is important to have a chance to study different methods of management and choose the one best for us in each situation. Once developed, contractures are difficult to treat because of the tendency to recur. Age of patient and joint stiffness play an important role in the functional outcome of surgery. Some of the factors to be considered when choosing the best option for release of contracture include the type of contracture, the state of surrounding skin and the expertise of the surgeon.

Despite the availability of numerous surgical options, flap cover gives the best result with minimal or no flap loss and better range of joint movement and reduced recurrence rate. Post-op the patient will have good range of motion but scarring may still be present with an unacceptable cosmetic appearance. Most of the time these scars will be hidden by clothing. Algorithm is one important way to share medical information. In general, good or excellent results were seen regardless of technique of release, without any cases of worse postoperative contracture than preoperative contracture.

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