Axilla and elbow 2
The patient in this example is the son of Maasai parents in central Tanzania. The burn wound he sustained to his left arm was deep, and without skin grafting took many months to heal. The healing process was complicated by malnutrition and anemia. Two years later, they came to Haydom hoping that something could be done to improve the function of the arm. The wound was healthy and there was an impaired range of motion in the axilla and elbow.
This example shows a variation on the design in the previous example with local flaps. This time, the surgeons choose a large Z-pasty combined with a jumping man instead of two jumping mans in a row.
The child sustained a burn injury at the age of 2 during the night, when the ashes of the fire were still hot. They went to Dodoma hospital where they received three months of wound care, but because the wound did not heal, they subsequently went to two other hospitals where the child received wound care and a blood transfusion, but no surgical care.
It was difficult for the family to get food because they had no money. The parents did not have cattle themselves but instead earned money by taking care of cattle for others, and by trading vegetables like tomatoes. Taking care of their child was taking too much of their time, meaning they were not able to earn a sufficient income and so they went home. Gradually the wound began to heal spontaneously until it was fully healed. Two years later, a pastor in Dodoma advised them to travel to Haydom when he had heard of a visiting surgical team treating burn scar contractures. The patient and his father arrived at the hospital after 9 hours of traveling by bus.
The boy presented with limited abduction and anteflexion of the left axilla and limited flexion of the elbow. On examination and palpation, there was a narrow band contracture with a clear fold extending from the chest to the left forearm. The side of the fold with good skin quality was mainly posterior at the axilla, with the armpit itself being healthy, as seen on photo 3.
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).
Postoperatively, the skin flaps were covered with Vaseline gauzes and tetracycline, with a layer of dry gauzes on top. The elbow was kept in extension using a plaster cast and the shoulder held in abduction. After five days, the dressings were removed to inspect the wounds but the plaster of Paris was kept on to maintain extension of the elbow for 4 weeks. During follow-up appointments, outcome measurements were recorded at three, six and twelve months.
At follow-up one year later, there was full range of motion of the shoulder in all directions (anteflexion, retroflexion, abduction and adduction, endorotation and exorotation). The function of the elbow and forearm (flexion, extension, pronation, supination) was also no longer limited.
We reviewed the patient for a final time two years after surgery. The father expressed that he had lost hope before coming to Haydom Lutheran Hospital as people had been telling him the arm could no longer be treated. The whole village was surprised when the boy returned with good function of the entire arm within just a few weeks of the operation. This shows the importance of communicating the availability of effective and affordable surgical care by community leaders, like a pastor in this example.
The team in Haydom learned to adjust the design of the local flaps according to the nature of the contracture and the availability of adjacent healthy elastic skin.