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Case

Axilla and elbow 3

In this case we show the treatment of the remaining contractures of the right axilla and elbow one year post-injury in Haydom Lutheran Hospital, Tanzania. The patient had previously received care here for his acute burns of the shoulder and upper arm.

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

Medical history

One year ago, the patient suffered a burn injury from an open fire (Photo 1). Despite surviving the injury, he required two surgeries to close the wound. The acute burn treatment involved a three-month hospital stay, during which the medical team did their best to provide appropriate care. However, even with their efforts, contractures in the axilla and elbow persisted after the wound had healed. It is important to note that the presence of contractures is not a failure of treatment, as they can occur even with adequate care. Nevertheless, it is reassuring to know that contractures often have successful treatment options.

Physical examination

During the physical examination, it was observed that the patient had linear band contractures in the axilla and elbow. Additionally, there were visible signs of previous skin grafts. Palpation revealed the presence of scarred tissue with reduced skin slack on the posterior aspect of the neck, axilla, and elbow. However, on the anterior aspect of the axilla and the medial aspect of the elbow, there was native skin with sufficient slack that could be used for a local flap. In terms of range of motion (ROM), the patient's shoulder abduction and anteflexion were limited to 80 degrees, while extension of the elbow was restricted to 120 degrees (Photo 2).

Surgery

In accordance with the burn scar contracture classification by Ogawa 2015, the axilla contracture in this patient was identified as a type III contracture. It presented as a linear band with diffuse scarring surrounding the band, primarily on the dorsal aspect (Photo 3).

Axilla:

To address the axilla contracture, a jumping man technique was planned. The procedure began with a straight incision, known as the "shoulders," made over the contracture band. The "legs" of the jumping man were positioned on the side with pliable skin (slack), while the "head and arms" were placed on the scarred side (Photos 4 & 5). Jungle Juice was used for hemostasis by infiltrating the surgical site. The initial incision followed the line of the contracture, and then the flaps of the jumping man were raised in a suprafascial plane (photo 6).

Elbow:

For the elbow contracture, the incision lines were marked (Photo 7). Similar to the axilla procedure, a straight incision was made over the contracture band, extending from the upper arm towards the elbow. Since this contracture was longer, it was necessary to employ multiple Z-plasties. The flaps were raised in a suprafascial plane, and interposition of the flaps was performed to achieve the desired length (Photo 8).

Postoperative care

The postoperative care involved splinting the elbow in maximal extension without applying pressure, and this position was maintained until the wound had fully healed. The photo provided showcases the significant amount of lengthening achieved at the conclusion of the operation.

Following the procedure, the wound and grafts were regularly inspected on days 3-4 post-procedure. It is important to note that if there is a foul smell emanating from the wounds, the examination should be conducted earlier. Additionally, daily checks are necessary to monitor the progress of the wound and graft healing process.

Outcome

One common complication observed in transposition flaps is the necrosis of the tips of the triangles. However, this can be mitigated during the surgery by creating broader tips. In the event that necrosis does occur, the treatment approach varies depending on the extent of the necrosis, ranging from conservative measures to surgical interventions such as debridement with or without grafting. Fortunately, this patient did not experience any complications.

The follow-up examination conducted after a span of 2 years reveals the outcome of the treatment.

Lessons learned

One important lesson learned is the effectiveness of using multiple Z-plasties in cases where there is a longer scar contracture accompanied by surrounding scarring and limited skin slack. This technique allows for better lengthening and release of the contracture, improving the functional outcome for the patient.

Another valuable lesson is the significance of the long-term patient-doctor relationship in burn injury cases. From the initial reception in the emergency room to achieving a positive final result almost three years later, the bond between the surgeon and the patient plays a crucial role. This connection was evident in a particular case where the child, as a gesture of gratitude, brought eggs as a gift for the surgical team during the final follow-up appointment. It highlights the deep appreciation and trust that develops between the patient and the medical professionals involved in their care. Such moments make the entire journey rewarding and reinforce the importance of providing comprehensive and compassionate care to burn injury patients.

Case

Axilla and elbow 3