Contractures in specific areas
Contractures from burn injuries are seen all over the human body, but some areas often present in a similar way. This enables us to provide useful tips and tricks from past experience.
Face and head
Burn contractures and defects on the face and scalp can cause functional impairment and social problems and isolation due to cosmetic disfiguration.
Functional problems are often seen around the eyes, due to loss or retraction of the eyelids causing lagophthalmos, ectropion or inadequate eye opening. Reconstructive surgery of the eyelid can be quite complex, and you should not perform this without proper training. However, contracture release and full thickness grafting are relatively simple procedures that can be of great help for these contractures.
Even relatively small grafts can make a big difference to eyelid function.
Contractures around the mouth can cause problems in lip function and thereby inadequate closure of the mouth. This can lead to impairment of speech, mastication and swallowing. Z-plasties can be very useful in this region, but sometimes grafts are needed – preferably FTGs. You can find the best donor sites around the ear or supraclavicular region, as they provide the best match in color and texture.
Defects on the scalp can lead to necrosis of the exposed skull, especially if there is no remaining vital galea or periosteum. In these cases, skin grafting has little chance of success, as there is no vital wound bed for the graft. You can use large rotation flaps of the scalp to close these defects. You can often close the donor site primarily, but if this is not possible, you can use a skin graft on the vital periosteum, with good chance of success. Another way of creating a vital wound bed for a skin graft is to chisel away the outer table of the skull. The cancellous bone can then be skin grafted.
Flexion contractures of the hand are common in young children that burn their palmar hands and fingers. The result is a mitten-like appearance of the hand, with the fingers contracted into the palm of the hand.
In most cases, you can obtain a complete functional range of motion after contracture release. In some cases, you may be able to use local flaps to cover parts of the created skin defect, but in almost all cases you will need skin grafts. We advise using full thickness skin grafts, as they provide a better skin quality on the palmar surface of the hands and fingers.
You can easily obtain sufficient skin for a graft from the groin. Do not take the graft too small; you are likely to need more than you think. The skin from the groin is good quality, and it is thin enough to be pliable and have a good take. The groin scar will be hidden under the clothing.
When you release contractures of the fingers, it is of utmost importance to fix the fingers in extension, as the body has a tendency to pull the fingers into a flexed position again. This will hamper the take of the grafts and facilitate recurrence of the contracture.
We strongly advise axial K-wires through all affected joints in order to provide a stable fixation. Often 1.0- or 1.2-mm wires are strong enough, and you can leave the wires sticking out of the fingertips for easy removal. It can be helpful to bend the K-wires at the tip to prevent them from getting lost inside the body. They usually stay in place for three to four weeks, until the full thickness grafts have healed completely. If a pin tract infection occurs, you will need to remove the K-wires earlier.
After removing the K-wires, the patient should perform exercises several times a day, and splinting in extension is recommended during the night. This should be done for an extended period of time, sometimes up to one year.
The ideal removable splint is made from plastic and has Velcro straps for fixation. These will not be available in many places, but a thick splint, made of Plaster of Paris and fixed with an elastic bandage will also be sufficient and will last for months, provided it is made thick enough.
Elbows and knees
Contractures of elbows and knees are often very similar: they have a scarred area on one side (lateral or medial) and the other side is unaffected (type III contracture). When the scar pulls up and away from the pivot point, it forms a fold in line with the axis of the extremity, thereby stretching the good skin on the unaffected side and enlarging the surface area. This means that on one side of the contracture, there is an area of good skin, and on the other side there is contracted damaged skin. Together they form the fold.
The good skin is ideally situated for a local flap – for example a 5-flap plasty, also known as a jumping man. In these cases, the flaps are made of good skin and you insert them into the release incisions made in the contracted skin. This works best if the two sides of the fold are close together. Due to the typical configuration of these contractures, they can often be released with local flaps only, without the need for grafts. However, do not hesitate to use grafts if you need to.
Hip/groin and shoulder/axilla
The hip/groin and shoulder/axilla regions are complex in their anatomy and functional mobility. It is crucial to correctly assess the contracture and the amount of release needed, as defects can be substantial and should not be underestimated.
In these regions, you will often need large flaps. The thoracic wall can provide a large flap that you can insert into the contracture after release. You can achieve this using a banner flap, or an asymmetrical Z-plasty (also called an interposition flap).
Often the burn scar, and therefore the contracture, is either on the dorsal or ventral side, but rarely on both. You should take the banner flap from the unaffected side to ensure good skin quality.
You can close the donor defect primarily, but if a skin graft is needed a split-thickness skin graft (SSG) will normally be sufficient, and it should not cause problems or risk recurrence if the design is well chosen. In the groin area, you can raise the banner flap from the inner aspect of the thigh or take it from the infragluteal region. You can design interposition flaps around a vascular pedicle that perforates the fascia and use these as perforator-based flaps, which you can island and rotate around their vascular pedicles (though this is beyond the scope of our guidance).