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Case

Axilla 1

The patient in this example presented at Haydom Lutheran Hospital in Tanzania with a severe broad contracture of the left axilla. Deep burns in the axilla commonly lead to adduction contractures. A deep burn on the anterior aspect of the shoulder can also cause rotational contractures (where external rotation is limited), as was the case for this patient. The boy presented in this example required two operations. The first procedure for the broad contracture needed skin grafts. At a later stage, a Z-plasty was performed to treat the less severe narrow band contracture that had developed after the first operation. We believe it is often indicated to perform additional surgeries in severe contractures. Good communication, aftercare, and follow-up are essential to obtain a good final result.

Medical history

The patient had sustained a burn injury as a toddler when his clothes had caught fire as he sat too close to an open fire which his family used for cooking. Due to financial limitations, the burn was not treated at a health care facility and it had taken three months for the wounds to heal. 

Since then, his arm had been clamped down by his body. He came to Haydom in the hope that treatment would enable him to wash himself properly, and in the future to pursue a career as a farmer where he would need to be able to plow the ground and carry heavy items. 

Physical examination

A broad contracture of the left axilla limited all movements of the shoulder. On palpation the scar was non-elastic and the anterior aspect of the axilla and the left side of the chest were predominantly affected. On the posterior aspect of the axilla and trunk, healthy, pliable skin was present, especially at the posterior border of the axilla. 

As mentioned, range of motion of the shoulder was very limited. Abduction, anteflexion and retroflexion were not possible. Rotation was limited but possible, as can be seen in the video.

Surgery

Surgery 1

As there was a short and narrow contracture where the band was fixed to the chest, the band could just be excised here. In the armpit one large Z-plasty was sufficient, and for the elbow the jumping man technique was used, with the legs of the jumping man on the healthy skin side laterally. You can see how difficult it is to understand the design of the reconstruction when drawn in two dimensions (photo 7). The three-dimensional pre-operative drawings (photos 4 and 5) are helpful, but to fully understand why this design is adequate, palpation is needed to be able to define the available ‘slack’ (excess skin combined with elasticity).


Surgery 2

A symmetrical Z-plasty was chosen for this linear contracture with a clear fold. The incision lines were marked with a straight line along the contracture band, this became the diagonal in the Z. The two limbs of the Z were drawn at an angle less than 60 degrees and had the same length as the diagonal line of the Z (photo 10, see also Infographic 2).

For hemostasis, the surgical site was injected with an adrenaline infusion.

Starting at the line of the contracture, the skin was incised. First, the anterior flap was raised in a supra-fascial plane (photo 11). Subsequently the posterior triangle was raised (photo 12).

The two flaps were transposed (photo 13) and the wound was closed

(photo 14).

Postoperative care

The wound was inspected after four days, after which the dressings were changed every two days. Immobilization of the axilla in abduction with plaster of Paris is sometimes recommended, but in this older child, instead of a splint, clear instructions were provided to keep the arm abducted at 90 degrees for the first 4 weeks. 

Unfortunately, necrosis of the FTG occurred (photo 8). Four weeks after the initial surgery, the necrotic tissue was debrided and the wound covered using a SSG as a minor procedure under local anesthesia, as the SSG was only small. This graft showed a good take, however, during follow-up the patient was still slightly limited in his activities due to a remaining adduction contracture. A remaining linear fold was seen, palpable as a string (photo 9). 

Abduction was limited to 70 degrees. Ante- and retro-flexion were also still limited, but to a lesser extent. After discussing the benefits and possible risks of a second surgery, he opted for a second procedure.

Outcome

Two months after the z-plasty

The Z-plasty was inspected five days after surgery, and two weeks post-procedure active exercises were started. Once the wound has healed, patients are advised to keep the scars smooth using Vaseline or an oily cream. 

In this patient, adduction, anteflexion and retroflexion improved significantly. 

Lessons learned

A well vascularized local flap, when feasible, generally provides better functional outcomes than skin grafts, mainly because it has the ability expand in the future. Local flaps can be combined with skin grafts if needed.

When planning a contracture release using a local flap for the reconstruction, pay careful attention to the location of the scar, the location of healthy tissue, and the available slack. Often there are multiple options. When possible, we recommend placing the healthiest part of the flap on the part of the defect closest to the pivot point of the joint where ability to expand is most needed. In this case, the late expansion is demonstrated by improved abduction when comparing photo 15 (after two months) and photo 16 (after one year).

We have experienced good results without immobilization of the shoulder with splints post-operatively at Haydom. The strategy instead consists of clear instructions for the patients and their caretakers to start active exercises early. When the availability of physiotherapists is limited, it is important to instruct the patients especially carefully.

In general, FTGs have a higher risk of failure compared to SSGs, however, in joint areas we opted for a FTG as it shrinks less when compared to a SSG. The failure rate of a FTG, however, is greater. When the FTG failed in this example, we choose a SSG as a second option with a lower risk of failure. 

The classic Z-plasty is a very useful technique in a linear contracture with equally distributed (relatively healthy) skin on both sides of the fold. Be aware that the length of the limbs of the Z-plasty are not simply equal to the length of the contracture but determined by the amount of slack in the direction opposite to the contracture. As a 60 degrees Z-plasty provides 75% lengthening, the limbs should not be designed longer than the slack plus 33% of the slack. If the contracture is much longer than the slack, two smaller Z-plasties are required instead of one.

Case

Axilla 1

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