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Axilla 2

The case presented here features a 10 year old girl who was treated at Haydom Lutheran Hospital for a 39% total body surface area (TBSA) full-thickness burn affecting her back, shoulders, and buttocks. Although the patient survived and the wounds healed, she developed contractures in both axillae. This case serves as an example of how contractures with a narrow band, typically forming a fold with good quality skin on at least one side, can be effectively treated using local flaps without the need for skin grafts.

The acute burn injury and its treatment were discussed in a previous case: Shoulders, back and buttocks

Medical history

One year ago, the patient sustained a burn injury from an open fire. She underwent multiple surgeries over a six-month period to close the wound using split-thickness skin grafts (SSGs). Despite receiving adequate wound care, contractures developed in both axillae.

Physical examination

During the physical examination, it was observed that the patient had developed contractures with skin folds in both axillae following skin grafting of the posterior trunk and arms. The range of motion (ROM) in the affected shoulders was limited to 90 degrees for both abduction and anteflexion. Palpation revealed scarred tissue with reduced skin elasticity on the posterior aspect of the axilla, while the anterior aspect exhibited healthy skin with adequate "slack" that could be utilized for a local flap. Prior to the surgery, the design of a jumping man technique was marked on the patient's skin.

Surgery

Contractures characterized by a single side of the fold being affected can be effectively treated using the "jumping man" technique. First, a straight line is drawn over the contracture band. The "legs" of the jumping man are positioned on the healthy side of the fold, while the "head" and "arms" are positioned on the scarred side.

Infiltration of the surgical site with Jungle Juice is recommended for hemostasis. An incision is made along the length of the contracture (Photo 6) and the flaps of the jumping man are dissected and raised in a supra-fascial plane (Photo 7). The five flaps are sutured in place. Photo 8 illustrates the significant lengthening achieved with the jumping man technique in this case.

Postoperative care

The wound was inspected on days 3-4 post-procedure. If a foul smell emanates from the wound, an earlier examination is recommended, and gentle cleaning with running tap water or 0.9% saline can be performed.

After three weeks, it can be beneficial to apply Vaseline to keep the scars smooth, although full range of motion is not expected at this stage (Photo 9).

Outcome

No complications were encountered, and shoulder function improved significantly.

Potential Complications: If the triangles created by the jumping man technique are too narrow, tip necrosis can occur. Therefore, it is important to avoid excessively narrow triangles and maintain a wider angle at the tip. Minor cases of tip necrosis can be managed conservatively, but if the necrosis is more extensive, surgical intervention such as debridement, a new local transposition, or a skin graft may be necessary.

Lessons learned

Lessons from the Local Doctors

In the case of severe burns, it is important to recognize that contractures can develop despite providing the best possible wound care. Although healthcare providers may feel frustrated by the development of contractures, it is crucial to understand that this is a normal occurrence in severe burns. Adequate wound care still plays a significant role in preventing the formation of extremely severe and broad contractures. Contractures that develop with proper care are generally more treatable and may require less extensive surgical interventions. It is worth noting the occurrence of folliculitis on the scalp which can be a result of using the scalp as a split-thickness skin graft (SSG) donor site for acute burn treatment (Photo 2). However, it is reassuring to observe that two years later the folliculitis had healed (Photo 10).

Lessons from the Patient and Her Mother

This particular patient had undergone five surgeries following the burn incident. The accident had a significant social and financial impact on the family, leading them to sell seven cows and rely on support from relatives and neighbors to secure enough food. During this challenging period, the husband had left the family, leaving the mother to care for her nine children on her own. However, during the follow-up visit two years after the burn injury, the mother expressed her satisfaction and surprise at her daughter's remarkable improvement. She shared that her daughter had regained the ability to play, run, and attend school just like other children. Despite the hardships faced, the mother managed to cope with the situation and remained hopeful for her daughter's recovery.

Case

Axilla 2

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