Elbow, wrist and fingers
This example shows a patient with a contracture of the elbow, wrist and fingers.
This young girl was presented with a contracture with a clear fold, but the fold had scarred skin on both sides and the contracture was extending over three joints (elbow, wrist and MCP joints of the fingers). In addition to local flaps, additional FTGs were also needed to treat the contracture. This example also illustrates how partial flap and graft necrosis can be managed successfully.
The child sustained a burn injury at one year old, and was treated locally with eggs and honey. The wound appeared to be small in the beginning, but was increasing in size after a couple of days. Over time it healed slowly at home but a contracture developed. The parents said they believed the child was being bewitched and though they only lived one hour away from the hospital, they explained that they thought that their daughter could not be cured by modern medicine. At 2 years of age, the girl was brought to the hospital because they had heard about visiting surgeons.
The girl presented with limited flexion of the elbow, wrist and fingers. On examination and palpation, a band contracture with a clear fold extending from the elbow to the dorsal fingers was found. Both sides of the fold had scarred skin that had lost most of its elasticity.
The elbow was released with the jumping man technique, and the wrist with a Z-plasty. Both techniques were combined with FTGs because there was not sufficient elastic skin available to use only a local flap to achieve full release of the contracture
(see FTGs marked in photo 4).
The skin flaps were covered with Vaseline gauzes and tetracycline, with a layer of dry gauzes on top. The elbow and hand were kept in extension using a plaster of Paris cast. After five days, the dressings were removed to inspect the wounds. If a FTG looks good after five days (photo 6), it does not guarantee that it will fully survive. Photos 7 (after 10 days) and 8 (after two weeks) show at least partial loss of part of the flaps and the FTGs. If the area is large, an extra procedure to graft the remaining defects with an SSG may be indicated. In this example and in this setting, the team chose to treat conservatively with wound dressings every other day, and continued the plaster of Paris cast to maintain extension of the joints. On discharge, adequate instructions for further care given verbally and written on a discharge form can be helpful.
Healing of the wound by secondary intention led to a second, more mild contracture of the elbow in this example (photo 12). The effect of this was only temporary because at follow-up six months later it had improved with exercises (photo 13), and at one year there was full range of motion in all movements. At the final follow-up visit, 18 months after surgery, only the little finger was still slightly contracted, but this did not limit the function of the hand.
The parents of the patient were happy with the treatment received from the hospital. They expressed that their daughter can now use her arm and hand normally, and can lift objects from the ground by herself. They learned that surgical treatment in the hospital is effective, and thanks to a poor patient fund it was also affordable for them.
This example demonstrates that if the contracture has insufficient surrounding healthy skin to be able to restore full motion of a joint with local flaps only, it can be helpful to add skin grafts.
For contracture release of clean wounds with a healthy wound bed, FTGs are used preferentially and are most often harvested from the groin and abdomen. However, SSGs can be harvested faster if there is no assistant who can harvest the FTG simultaneously during the release, and SSGs have a higher chance of taking, providing a lower risk of graft failure. This case shows that partial graft failure does not always need to be treated with new grafts in order to obtain a good outcome.