Axilla, elbow, wrist and fingers
This example shows a girl with a severe contracture involving the axilla, elbow, and dorsal side of the wrist and fingers. Prior to presentation, two operations had been performed to improve the function.
The patient sustained a severe burn at the age of 9 months and had been treated at home until the wounds on the right arm and head had healed. The child survived but contractures had developed. At the age of 15, her older sister noticed the announcement that burn care contractures would be treated at Haydom Lutheran Hospital, so the patient was taken there.
On examination, a severe contracture of the upper right extremity, with a scar involving the shoulder, elbow, wrist and digits was seen. The range of motion of the shoulder, elbow, wrist and digits was very limited in all directions, severely limiting the function of the limb.
The incision sites were marked and Jungle Juice was used for hemostasis.
The interposition flap was taken from the anterolateral side of the chest in the suprafascial plane, and rotated onto the axilla. The donor site was grafted with a SSG.
The ‘jumping man’ technique was performed at the elbow, with the ‘legs’ of the man positioned on the healthiest side. This ensured that most of the healthy, expandable tissue was placed onto the scarred area. An extra FTG was needed to maximize the extension of the elbow, but due to stiffness in the joint capsule full extension was not achieved.
Wrist and digits
The contracture was incised over the joints and care was taken not to harm the dorsal branch of the radial nerve. After careful dissection of the scar down to the plane just above the tendons, at the level of the MCPs, the extent of the contracture was able to be visualised. K-wires were placed to keep the joints in a flexed position for 6 weeks. The skin defect was covered with FTGs over the joints, and SSGs over the other areas.
The second surgery was performed one year after the first.
During the second surgery, the elbow and dorsum of the hand were released again to improve function. The same techniques as before were used for both the elbow (jumping man technique) and the wrist/digits (FTG with the abdomen as the donor site).
The post-operative management was also kept the same: Vaseline gauzes with tetracycline were applied and the elbow was kept in extension with a POP backslab. The POP and the bandages were changed after 5 days and the backslab and K-wires were removed after 6 weeks.
Vaseline gauzes with tetracycline were applied and the elbow was kept in extension with a Plaster of Paris (POP) backslab. The girl was instructed to keep the shoulder in 90 degrees abduction. The POP and bandages were changed after 5 days, and the K-wires removed after 6 weeks.
One year after the second operation we visited the girl at home where she now lived with her older sister. She was happy with the result and although the hand was not fully normal, she did not want further surgeries as the function was sufficient. She was able to carry out all daily activities and even writing was now possible with the hand.
For the doctors in Haydom this was one of the first severe contractures they learned to treat during the training program, provided by visiting plastic surgeons from the Netherlands.
They learned how local flaps can be effective, especially on the joint surfaces. A good example of this was the first procedure at the axilla, where a local flap from the chest was used to cover the defect in the axilla. The remaining defect on the chest needed to be grafted. This demonstrates a common principle in plastic surgery: ‘Rob Peter to pay Paul, but only if Peter can afford it.’ The chest can afford to provide a flap for the axilla and grafting the chest afterwards will lead to a scar but not a contracture, as it is a less mobile area.
In severe cases, like the patient presented here, a staged approach consisting of multiple surgeries is often required to achieve the optimal result.
The girls and her family considered the operations a success. However, two years later, when we visited her at home where she was living with her older sister and her sister’s five children, they told us that affordability had been an issue for them. For the first operation the family was able to pay the hospital costs, but they could not afford the second operation. The doctors had initially explained that the poor patient fund would pay for the procedure, but afterwards they were informed by others that they had to pay. This meant that they were now afraid to return to the hospital. The functionality of the shoulder was good, but for the hand and arm it was not yet perfect, but she was able to use the hand and did not want further surgery.