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Case

Knee contracture

This example shows the treatment of a severe contracture of the left knee, after a burn wound caused by an open fire in rural Tanzania. The girl survived the large burn wound, but the acute wound had to heal by itself as she was treated at a hospital where surgical burn care was not available. Her wounds healed slowly, and when she arrived at Haydom Lutheran Hospital six months after the injury occurred, the remaining broad contracture that she had developed was treated with a release, local flaps, and skin grafts.

Medical history

This 5 year-old girl was playing with other children in the street around a fire, but she came too close and her dress caught on fire. A passerby tried to put out the fire and probably saved her life, but after removing the charred clothes there was a large burn wound on her left leg. Because there was no transport available the same day, the father arrived with the child at the local hospital in Tanga the next day. The patient became very weak and malnourished, but she survived and the wound started to heal with the help of daily dressings. Skin grafting was not possible in this hospital, and it took six months before she was strong enough to go home again, though there was still a wound and the girl was unable to walk because she could not extend her knee. Her father brought her to Haydom Lutheran Hospital, where she was seen on the screening day as part of a reconstructive surgical training camp.

Physical examination

The girl had a contracture of the left knee, limiting extension to 90 degrees. A circular open wound was still present on the middle part of the upper leg.

Surgery

Surgery 1

The open wound on the upper leg was treated with a SSG taken from the upper right leg. The broad contracture was treated with a Z-plasty, in combination with a FTG that was taken from the groin to cover the remaining defect.

Surgery 2

The team decided to perform a second surgery, adding an SSG to the new wound on the posterior aspect of the knee. Post-procedure, the knee was again immobilized in extension with a POP back slab. Five days later, good take of most of the SSG was seen (photo 9).

Postoperative care

1. Vaseline gauzes with tetracycline were applied to the wound, and the knee was kept in extension with a plaster of Paris (POP) back slab (photo 5). The POP and the bandages were changed after 5 days (photo 6), but unfortunately most of the Z-plasty flaps did not survive. After two weeks the dead skin had come off, and new granulation tissue was present (photos 7 and 8).


2. For the next few weeks, the POP was applied as a full cast to allow mobility with the cast, and was changed every 2 weeks. Six weeks after the second surgery, the wounds had healed and the ‘above the knee full POP treatment’ was stopped. The father and daughter were then free to travel back home, however, the physiotherapists instructed the relatives to ensure that the patient performed exercises to improve extension of the knee as much as possible, since full extension had not yet been achieved. The girl and her father were highly committed to the exercises, and the knee function improved over time (photo 10). After six months, the knee function became as good as the non-affected right leg (photos 11 and 12).

Outcome

The extension function of the knee remained normal for this growing child over the subsequent two years of follow-up.

Lessons learned

The father was very happy with the special burn patients’ room on the pediatric ward in Haydom, with specialized nurses who he felt had treated his daughter very well. The girl had been provided with adequate pain relief to minimize her suffering. The instructions from the physiotherapist to stretch the knee frequently every day were effective post-procedure. 

It took 19 hours of traveling to reach the hospital, where surgical treatment was possible and affordable for them. For the one-way journey to the hospital for the follow-up appointment, they showed the team their 8 tickets from different modes of public transport (photo 17). The father of the child therefore requested that local surgeons learn to perform skin grafting at an affordable price in the regional hospitals in his country.

Case

Knee contracture

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