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Case

Wrist and fingers, dorsal side

This example highlights the case of a 22-year-old woman who suffered severe contractures on both hands after sustaining burn injuries from a gas bottle explosion. The contractures caused extension of the wrist and metacarpophalangeal (MCP) joints, as well as flexion of the proximal interphalangeal (PIP) joints. She underwent a series of surgeries to address the contractures and regain hand function.

Medical history

The patient initially received treatment at a hospital in Dodoma, Tanzania, but skin grafting was unavailable. Over time, she developed contractures and became dependent on her parents for care. Realizing the challenges she would face in the future, she sought treatment at Haydom Hospital, located 350 km away.

Physical examination

Examination revealed broad band contractures on the dorsal side of both hands, leading to the abnormal positioning of the joints. The decision was made to treat each hand separately, starting with the right hand.

Surgery

Surgery 1

The release incision was carefully drawn on the skin (Photo 3). The contracture was then released through meticulous dissection of the scar tissue along a line perpendicular to the metacarpophalangeal (MCP) joints (Photo 4). The surgical team was prepared to utilize a groin flap in case a non-graftable surface, such as fully exposed extensor tendons, was encountered. However, full thickness grafts (FTGs) have shown high success rates even when tendons are partly exposed, making it the chosen reconstruction technique in this case. To stabilize the MCP joints in flexion, K-wires were used (Photo 5 & 6, and Video).

Surgery 2

One year later, the patient underwent the same procedure for the left hand (Photo 7). The incision lines were marked (Photo 11), and Jungle Juice was used for hemostasis during the infiltration process (Photo 12). Under general anesthesia, the surgeon performed the surgery.

In the movie below, the procedure is demonstrated, showcasing the "pushing technique" using the belly of the blade. Traction is applied to the scar tissue to break it without causing harm to vital structures such as blood vessels, tendons, and nerves. The audio in the video includes the sound of a pulse oximeter and the distinctive sound of breaking scar tissue.

Although the patient also had flexion contractures of the PIP joints, it was determined that performing a contracture release on both sides of the fingers would pose a high risk of failure. To maximize functional improvement, the focus was placed on addressing the MCP joints and thumb (Photos 13 & 14).

Postoperative care

After the procedure, the grafts were carefully examined on the fourth day. If any foul smell was detected earlier or if there was pus underneath the bandages, an examination would have been conducted sooner. In such cases, the wounds would be rinsed meticulously with normal saline to ensure proper cleaning.

Following a six-week period, the K-wires used to stabilize the MCP joints were removed, and the patient began engaging in exercises to promote functional recovery.

Outcome

The grafts on both sides of the hands successfully healed without complications. To mitigate the risk of hematoma formation, which can lead to graft failure, multiple small holes were created in the FTG to facilitate drainage.

Twelve months after the second operation, the patient exhibited good hand function in both hands, indicating a positive outcome of the surgical procedures.

Lessons learned

Throughout the course of treatment, valuable lessons were learned by the local doctors involved in the case. They discovered that the pushing technique, utilizing the belly of the blade and tension on the contracture tissue, proved to be an effective and safe method for releasing contractures. This technique allowed for the division of scar tissue while preserving important structures such as tendons, dorsal vessels, and nerves.

From similar cases, it became evident that the maximum range of motion achieved after a contracture release would not exceed what was attained and temporarily fixed during the operation. As a result, it is crucial to immobilize the joint in the furthest position possible to counteract the contracture and optimize functional outcomes.

Contractures causing extension of the metacarpophalangeal (MCP) joints are commonly observed due to the thin skin on the dorsal side of the hands. This understanding highlights the significance of addressing such contractures in the management of hand burns.

The patient initially lost hope after months of unsuccessful treatment with daily dressings, accepting her situation as hopeless. It was a challenge to convince her to undergo the operation as she had resigned herself to her condition. However, she emphasized the importance of raising awareness about the possibility of surgical intervention for burn contractures. Following the first operation, she eagerly sought treatment for her second hand, but financial constraints posed a significant concern. Eventually, she managed to borrow money from one of the doctors to afford the surgery. Her experience underscores the need for affordable surgical options for patients in similar circumstances. With improved hand function, she is now capable of caring for her parents and is actively seeking employment in a restaurant, demonstrating the positive impact of the surgical intervention on her life.

Case

Wrist and fingers, dorsal side