3. Introduction
Scar contracture is the common leading cause
disabilities in burn patient
Wound healing the wound & scar edge contract
approaching the neighboring sxr
Scar contracture mostly occur due to physical
inactivity & patient preference to position comfort
Prevention of burn contracture by proper positioning
,splinting & physiotherapy is the best way to avoid
contracture
4. Contraction is normal dynamic physiological process
by which the healing area decrease in size due to
myofibroblast
Retraction is consequence of contraction over
surrounding normal tissue
Contracture is final result of this vicious process over
the joint area which affect the joint movement
5. Factor that increase risk of contracture include
-depth of injury
-location
-poor dressing , splinting and physiotherapy
-delay in surgical RX
6. Prevention of post burn contracture
Body position and splinting
-neck in slight extension
-axilla in abduction 90-120 degree
-elbow in extension
-wrist in 30 degree extension
-hand MCP 70 degree of flexion
IP extension
thumb palmar abduction
Elevation of extremities
7.
8. Prevention
Physiotherapy
Early excision and grafting
Intermediate phase of recovery continues use of
splint and pressure dressing is important
9. Classification
MASCC universally valid for all joint to provide idea
severity of & algorithm for RX
-three basic measurement width ,height & length its
relative to affected joint
-width narrow or wide
-length short or long
-height high or low
10.
11.
12.
13. MASCC has four type
-type A narrow + long or short + high
-type B narrow + long or short +low
-type C wide + short +low
-type D wide +short + high
-Group 1 narrow aren’t sever in term of functional
impairment RX local rearengment of tissue ,graft
-group 2 wide scar cause sever functional
impairment RX is by FC or perforator based flap
14.
15.
16. Management
Preoperative evaluation
-identify scar band which cause contracture
-assess degree of contracture & motion of joint ,NV
-inspect local soft tissue quality
-hand look for the web space
-examine entire extremities
-look for donor site
-xray of the joint
17. Principle contracture release
-contracture release always start from proximal
joint & whose correction give maximum benefit
-never graft bare structure and central part of joint
-always try to cover central part of joint with flap
-one extremities at time
-always consider use of tourniquet
18. -always try to achieve maximum release on table
-before putting graft or flap put the hand
-for scar release the incision is made in scar across
the joint in line with axis of rotation
-all fibrous tissue should be removed
19. - the scalpel used by pushing method not slicing
-always be aware of the critical sxr that can be injured
-preserve & reconstruct sxr that stabilize the joint
-never expect perfectly planned flap will fit as planed
-don’t delay surgery especially in children
20. Non surgical treatment
Pushing or pulling of extremities that stretch
the scar & the tissue
-this can be achieved by serial splint
-skeletal traction
21. Axilla
Area bounded by anterior & posterior axillary fold
Cause of concavity of axilla with full thickness burn
if not excised & grafted early there risk for significant
contracture
~27% pt develop contracture with early excision &
graft or with superficial burn compared with 95%
develop contracture when no splint is used
22. Axillary contracture can be classified
-1 linear scar contracture at either axillary fold
-2 with adjacent tissue scarring
-3 both fold is involved with spare cupola
-4 entire axilla is involved
Type 1 z plasty , yv advancement flap ,graft
Type 2 graft ,z plasty , fasciocutaneous flap
Type 3 & 4 faciocutaneous , parascapular , LD flap
23. Anterior fold we can use the uninvolved medial ,
lateral side , lateral thoracic wall
Posterior fold transposition flap from lateral ,medial
wall , faciocutaneous flap from posterior trunk, long
head of triceps ms
Both web contracture with spared cupola for larger
defect we may need two flap for release should be
RX as isolated problem
Total axillary contracture graft, parascapular , LD
flap , pectorals major ms flap , free flap
24. Surgical technique
Z plasty-multiple z ,3/4 z plasty or double opposing
can be used if adjacent tissue is spared
y/v advancement flap used for minor contracture
Inner arm flap can be used for anterior web
contracture based on ulnar collateral artery
FC flap based on medial septocutaneous vessel from
direct branch from brachial artery
Triceps long head
Free flap & tissue expander
28. Post operative period
-splinting especially for graft
-physiotherapy
Complication
-brachial plexsus injury
-graft failure ,flap necrosis
-recurrence contracture
-transposition of axillary hair
29. Elbow and wrist
Elbow contract usually in flexed position and wrist in
either flexed or extended
Thorough physical exam is important
Release Surgical
-z plasty
-graft
-flap for sever case of contracture
Thick non meshed STSG can be used after elbow and
wrist contracture release if joint is supple , NV sxr
non exposed
30. For simple limited band contracture we can use z
plasty or v/y flap
Sever case elbow contracture we use flap like medial
& lateral arm ,PIA ,radial forearm flap ,LD flap
For wrist PIA ,groin flap
Free tissue transfer ,tissue expander
33. Hand contracture
Restoring hand function is primary goal
Palmar contracture mostly seen in pediatrics or adult
with seizure disorder
Treatment
-FTSG or STSG can be used
-flap
34.
35. Web space deformity
Web space contracture is due to scar band
obliterating the dorsal aspect of the web
classification- grade 1 ¼ distance b/n MP & PIP
-grade 1 ½ distance
-grade 3 ¾
- grade 4 >3/4
-surgical RX VM plasty, four flap z or jumping man
-as grade increase there is need for graft increased
36.
37. Adduction contracture its usually 1st web space
problem
-It is due to muscle problem
-RX the skin is released with 4 flap z or jumping man
& adductor muscle is released
Finger contracture tendon s & joint capsule may
contribute
-RX release of contracture and graft
-in case of NV exposed flap
38. Extension contracture common due to thin dorsal
skin
-RX surgical release graft , 3/4 z plasty for small
MCP joint defect ,PIA ,groin flap
-fat grafting
39.
40. summary
Prevention of post burn contracture is the best way
to avoid contracture
Thorough physical examination
Post operative splint and physiotherapy
41. Reference
Functional & aesthetic reconstruction of burn
Total burn care
Global reconstructive surgery
Burn surgery reconstruction & rehabilitation
Sever skin contracture management
Editor's Notes
Among three consequence of burn deformity ,contracture & tissue defect contracture is leading cause of disabilities
Myofibroblast join one another and provoke the underlying tissue to move concentrically
Contraction differ from contracture it can be used as therapeutic purpose to decrease the size of z wound and it can be modified by splinting ,pressure ,histamine & serotonine
Injury over volar aspect of joint are at more risk
Without early excision & graft ,splint & physioterapy post burn scar contractureis inevitable
Shoulder figure of 8 splint or airplane mood splint ,elbow 3 point extension splint
Edema tend to develop in the dorsal surface of hand which prevent laxity of dorsal skin this put MCP in extension position the collateral ligament are shorten and become thight =stiff MCP in extension , this also cause loos of z balance b/n intrinsic and extrinsic extensor causing IP joint flexion
The goal of exercise is to maintain functional integrity of the joint and muscle strength
Intermediate phase of recovery the period from 2nd month to 4th month & cicatrical process continues so splint and pressure dressing should continue
Pressure dressing it decrease tissue swelling and soften the burned scar ideal pressure is 35mmhg
Narrow if it involve <50% joint surface can be cord like or sail like ,wide if it involve >50% joint surface can be isolated and thick or 2 or more narrow scar band ,short if length of scar is < width ofjoint & if it is >width it is long
High if distance b/n health skin flexion crease to mid point scar band free border >50% width of scar &if it is less it is low scar
Group classification is more important than type which allow the surgeon complexity of surgical procedure that will be needed
In case of prolonged contracture there may be growth abnormalities ,heterotopic ossification which may limit the range of motion even after soft tissue contracture release
Usually there loss of what is gained during surgery post operatively
Elbow elbow brachial artery and median n ,elbow the biceps ms might be limiting factor for extension and this is important elbow flexor can’t be transected
Wrist median & radial n fairly superficial can be injured other dorsal sensory branch of radial & ulnar n ,medial & lateral antebrachial n
Delaying surgery will affect the growth of joint & bone & also hv psychological impact
This is especially important for contracture caused by prolonged immobilization & there may be breakdown of skin
The bondary anteriorly pec major ,posteriorly teres major & superiorly 1st rib & axilla
Content axillary vessel ,brachial plexsus ,LN
Type 2 z plasty there is risk for necrosis cause of compromised vascularity of the scared flap
Type 3 & 4 graft there will be deeper bed ,risk of graft loss & contracture recurrence is high
With use of z plasty or advaancement vy or yv flap local skin as much as possible should be non scarred & care need to be taken not to rotate axillary hair
In case of local flap like z or advancement flap need to be used cautiously in case of adj tissue scared which makes the flap inelastic and subject to necrosis
Dorsal trunk faciocutaneous flap may become large for posterior web contracture
If vital sxr are not exposed skin graft is the simplest technique& sufficient
The disadvantage with ms LD , pec major flap is excessive bulk this can be avoided by using faciocutaneous flap
The problem with skin graft need long term splint ,intense physiotherapy & risk of recurrence
The disadvantage with z plasty if the skin is scared the is risk for tip necrosis
y/v advancement flap the flap is advanced not raised from adjacent tissue avoid risk of necrosis
FC FLAP based on medial septocutaneous vessel the perforator are arranged in vertical line from insertion of pec major to few cm above insertion of media epicondyle based on direct branch from brachial artery passing through medial IM septum , the skin island is designed longitudinally following the groove b/n triceps and biseps
Triceps long head flap used without compromising the function and vascularity of the flap and has isolated vascular pedicle for the long head at the level of teres major ms the skin is incised longitudinally b/n olecranon posterior axillary fold upto the deep facial then the two head is separated long head is more medial , care should be taken not to damage the radial n
7 flap plasty the gain in legth is about greater or equal to 180 %
¾ z plasty or banner flap length to width ratio of 5:1 can be used
Thoracodorsal perforator flap as large as 11 by 27 cm can be elevated and donor site is closed primarily, the marking is made from posterior axillary fold to posterior superior iliac spine this demarcate lateral border of LD MS ,THE 1ST musculocutaneous perforator is demarcated by 8 to 10 cm below axillary fold & 2cm medial to the lateral border of LD ms
For flap no need for splint & physiotherapy can be initiated immediate post op period
Axillary hair may be abnormaly located in case we use large single z ,or v/y flap
Dorsal wound in extended & volar wound in flexed position
Local tissue compared with graft it is better cause it is more resistant to contracture
At two week if the wound is healed physiotherapy can be started
For 2-3 month the splint is continued to be removed only for exercise and after 3 month night time splint is continued
Reconstruction step should planned according to functional importance of pt daily activites so wrist is 1st then thumb then the finger
Web space contracture is most common deformity seen after hand burn
Adductor ms is fibrosis is the main cause
Flap option include dorsal metacarpal artery ,cross finger ,littler flap
Finger contracture after dealing with the skin contracture their may be need for tenolysis , capsulotomy & release of collateral ligament
Splinting after finger extension can be achieved by k wire
With graft it can compromise the tendon glide if Parthenon is compromisedRestricted joint capsules and/or ligaments necessitate concurrent capsulotomies to achieve improved range of motion. Deep dorsal or palmar burns may result in direct injury or scar adhesions to the underlying extensor or flexor tendons. Tenolysis is performed as needed; however, exposed tendons may require flap coverage.
Fat grafting it improve contour deformity also tendon gliding in previously skin grafted area
