Wrist and fingers, ulnar side
Burns on the dorsal side of the hand can lead to contractures, causing the wrist and MCP joints to be fixed in extension. In the experience of the doctors at Haydom Lutheran Hospital in Tanzania, in young children severe scald burns are the most common cause of contractures on the thin-skinned dorsal side of the hands. This example shows a child with a contracture on the ulnar side of the wrist and hand that was caused by an open fire in the house.
Medical history
This example shows a 5-year-old boy, who came to the hospital 3 years after sustaining a burn injury that had led to an extension contracture of the wrist and fingers.
No treatment was given in the acute phase of the burn other than traditional herbal medication.
Physical examination
Flexion of the wrist was not possible due to the wrist and MCPs being fixed in hyperextension.
Only the function of the thumb was preserved.
Surgery
Contracture release of the wrist and MCP joints was performed, followed by reconstruction of the defect with a FTG from the groin. The little finger was so damaged that it had to be sacrificed, enabling the use of the skin covering it for the benefit of the ring (fourth) finger. Standard Vaseline gauzes with antibiotic ointment were applied, and a plaster of Paris (POP) cast was used to keep the wrist and MCP joints in a flexed and radially deviated position.
Postoperative care
Dressings were changed every 4 days during the first 2 weeks post-procedure, and the POP immobilisation was maintained for 8 weeks.
Later, the physiotherapist provided instructions for at-home exercises and gave advice regarding the follow-up of the case over the next two years.
Outcome
Graft take was 100% and there was full functional recovery of the wrist and remaining three fingers.
Lessons learned
This was one of the first severe contracture patients to be treated at Haydom Lutheran Hospital. Thanks to a dedicated physiotherapist, the aftercare was very good and the patient was followed-up for two years.This example motivated the team to professionalize and structure the care for similar patients in the following years.
For this broad contracture, without available skin for local flaps, treatment consists of a release of the contractures and covering of the defect with a FTG. In severe cases, especially when the patient is older, there may be difficulties regaining a normal position of the wrist and fingers due to shortened tendons. In such cases, there are several options depending on the experience of the surgeon and the severity of the contracture, including accepting an improved but not fully anatomically normal position after the procedure (with later evaluation of whether a second procedure is needed), or tendon lengthening. Even a proximal row carpectomy or joint arthrodesis can be a good option in certain specific situations when all other options failed.
