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Case

Fingers, palmar side

In this example from Tanzania, we present a young boy with flexion contractures of four fingers on the palmar surface of the hand, to show how to perform a release and coverage with local flaps and FTGs.

Medical history

A five-year-old boy presented, complaining of being unable to “open” his right hand, i.e. he could not extend his fingers. As a toddler he had sustained a burn at home, when hot porridge had caused a burn wound on the palmar side of his hand. The burn wound was not treated at a health facility because the child did not complain, and instead just clenched his fist. Only weeks later, his parents realized that their son’s fingers could no longer extend. Recently, by word of mouth, relatives of the patient had heard that such scars could possibly be treated at Haydom, therefore the family sought medical help at the facility.

Physical examination

Digits 2, 3, 4 and 5 were flexed at the PIP joints and (slightly) at the MCP joints. Extension was limited to approximately 120 degrees. There was no reduced sensation in the digits or vascular impairment, and the flexor tendons were functional to obtain full flexion.

Surgery

To assess the size of the required graft, the contracture release was first performed under general anesthesia. 

The steps were as follows: 

1. The patient was positioned in prone position with the right arm resting on an arm table.

2. The lines for the incision were marked, perpendicular to the direction of the contracture.

3. An antiseptic solution was applied and the patient was draped. 

4. Prior to making the incision, the surgical site was injected with an adrenaline solution for hemostasis.

5. The skin was incised over the marked lines and the fingers held in extension. To release the fingers, the scar tissue was cut through under tension, following the anatomical plane of where the skin used to be before the burn occurred. If a gentle approach is taken, using only slight pushing pressure while handling the scalpel, the underlying (more elastic) vital structures will not be damaged. 

6. As seen in photo 4, bilateral triangular local flaps were designed to cover the PIP joints. Due to a lack of available tissue in this case, they were quite small. 

7. After the release, K-wires are usually placed in the fingers to prevent flexion during the healing process of the skin graft. They are inserted at the tip of the distal phalanx and extend into the metacarpal region. In younger children such as this patient, a needle is used instead of a K-wire. In this child, because the DIP joints were not affected, the needles were inserted at a lower level, just distal to the PIP joints.

8. A FTG from the groin was used to cover the remaining defect.

9. For fixation of the FTG, absorbable 5.0 suture material for transcutaneous, continuous sutures was used. In doing this, we were aiming for a perfect fit with good contact between the FTG and the wound bed (photo 5).

Postoperative care

Besides dressing with Vaseline gauzes, antibiotic ointment, and a bandage, a plaster of Paris (POP) splint was used to protect the hand with the needles in, holding the fingers in extension. The graft was inspected five days after surgery. If warning signs (such as a foul odor) occur, the bandage should be removed earlier. After the first dressing on the ward, the dressing is changed and inspected every two days if there is no evidence of infection. 

Seven days after surgery there was minimal swelling and no signs of infection (photo 6). Unfortunately, this patient had a complication of a wound infection, and 40% of the FTG did not fully take. 

The wounds were dressed with tetracycline ointment for 4 weeks, resulting in secondary closure of the wound. The continuation of a POP cast to maintain extension of the fingers until the wounds had healed was essential, as the needles had failed to stay in position.

Outcome

The patient came for follow-up appointments at one, three, six and twelve months. Even the fingers where the FTG did not fully survive achieved relatively good extension.

Lessons learned

Burns on the palmar side of the hand often lead to flexion contractures of the hand and fingers. Flexion contractures of the hand and fingers are a massive constraint on the range of motion and gripping power. The natural reaction of a patient with a burn wound on the palmar aspect of the hand is to keep the fingers flexed as it closes the wound quickly; however, this leads to a severe contracture. This disabling condition can be prevented by splinting the hand in extension and utilizing skin grafts within the first weeks after the injury.

If broad contractures of the fingers occur, contracture release with K-wire fixation of the joints in extension, and coverage with local flaps and FTGs is recommended to obtain a good result. It is strongly recommended to keep the fingers in full extension at all times, as long as the wounds are healing. POP is usually less effective for this because young children are able to move their fingers inside the POP cast. As seen in this example, needles can be an alternative to K-wires, but they may be accidentally removed more easily, as happened in this case. 

After the first 4 weeks of immobilization, physiotherapy is important to improve the range of motion and prevent the formation of new contractures. When physiotherapy is not available, good instructions to the parents can be effective when patients are compliant. The immobilization in extension with K-wires shows good results in the long term, even in cases with loss of parts of the skin graft, similar to this example.

Case

Fingers, palmar side

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