Postburn shoulder medial-adduction contracture: anatomy and treatment with trapeze-flap plasty

Concepts in soft-tissue reconstruction of the contracted hand and upper extremity after burn injury

Burns and their subsequent contracture result in devastating functional and aesthetic consequences which disproportionally affect the upper extremity. By focusing on reconstruction with analogous tissue and utilizing the reconstructive elevator, function can be restored concomitantly with form and aesthetic appearance. General concepts for soft-tissue reconstruction after burn contracture are presented for different sub-units and joints.

Non-Invasive and Surgical Modalities for Scar Management: A Clinical Algorithm

Scars can lead to aesthetic and functional impairments. The treatment of scars requires meticulous planning and an individually adapted therapeutic strategy. A conceptual algorithm for scar treatment makes everyday clinical work easier for the practitioner and offers more safety for the patient. Based on a retrospective analysis of 1427 patients who presented for treatment of a variety of scars, we developed an algorithm for scar management and treatment. The treatments are presented using case descriptions. Additionally, an electronic search of MEDLINE, EMBASE, and ClinicalTrials.gov databases was performed utilizing combinations of relevant medical subject headings for "scar treatment", "hypertrophic scar treatment" and "keloid treatment". Reference lists of relevant articles and reviews were hand-searched for additional reports. Observed outcomes included: conservative scar therapy, minimally invasive scar therapy, and surgical scar therapy using local, regional and free flaps. With this work, we provide an algorithm for safe scar treatment. For better understanding, we have described a clinical case for each algorithm modality.

Trapezoid Advancement Flaps for the Treatment of Severe Upper Extremity Burn Contractures Limiting the Risk of Recurrence

INTRODUCTION

Severe postburn contractures can lead to partial or total loss of function of the limbs, with devastating socioeconomic and psychosocial impact on the individual, especially in low- and middle-income countries. We present a surgical technique for the treatment of severe burn contractures with the purpose of limiting recurrence of the contracture after surgery, which was developed based on the observation that in most burn contractures, one side of a contracture has unburnt, soft, and pliable healthy skin. By advancing this skin as a flap over the joint crease, a bridge of healthy tissue is interposed. We postulate that the pliable skin, together with the fact that secondary wound contracture progresses away from the joint in the skin-grafted areas adjacent to the flap and not over a mobile joint, promote healing, prevent skin graft breakdown, and limit recurrence of the contracture in the long term.

METHODS

We retrospectively analyzed data of all patients who have undergone surgery for severe burn contractures of elbow and axilla by means of our technique on the MV Africa Mercy between January 2013 and February 2014.

RESULTS

In 27 patients (19 female, 8 male) with a mean age of 16.4 years, shoulder range of motion improved significantly from preoperative 111.0° to postoperative 149.4° of abduction-adduction. The elbow range of motion improved from preoperative 76.6° to postoperative 108.6° of flexion-extension, with a significant reduction in the residual elbow contracture from 60.5° preoperatively to 18.5° postoperatively. The average follow-up was 3 months (range, 1.5-7 months).

CONCLUSIONS

We conclude that this relatively simple and safe technique limits the risk for early postoperative healing complications and recurrence of the contractures in the long term.

Free flaps in scar treatment

Introduction:

Scar management needs defined concepts and an algorithm to restore functional and aesthetic units. After an unsuccessful conservative treatment, surgical measures provide a vast spectrum of possibilities for remediation. The spectrum of possibilities consists of excision and Z-plasty, regional flaps, vascularized pedicled flaps, tissue expansion, and finally free tissue transfer. Severe scarring and highly destructed tissues with inferior functional and aesthetic units can be effectively treated with radical excision and free flap reconstruction. The complexity of flap architecture and tissue qualities allows for an individualized approach. Specific attention should be paid to the long-term consequences of severe scarring with progressive loss of functionality.

Materials and methods:

We worked out the most common surgical approaches and treatment algorithm for a stepwise and effective approach. Part of this algorithm is a seven-step surgical approach.

Results:

This article provides modern plastic and reconstructive surgery concepts with an algorithm for scar management.

Discussion:

The treatment of scars follows an algorithm with the level of complexity of techniques adjusted to the individual case and the conditions. Disabilities induced by scarring can lead to further functional loss. In these cases, surgical strategies have to be considered.

Recurrence of post burn contractures of the elbow and shoulder joints: experience from a Ugandan hospital

BACKGROUND

Recurrence of post-burn contractures, following inadequate management of post-burn contractures (PBC), is under reported. It is associated with multiple operations and an increased cost to patients and their families. The purpose of this study was to determine the frequency of recurrence of PBC of the shoulder and the elbow joint three months after surgical intervention and the associated risk- factors.

METHODS

This was a prospective cohort study conducted at CoRSU hospital from March 2012 to November 2014. All patients with PBC of the elbow and/or shoulder joint who consented to be in the study and met the inclusion criteria were enrolled. Data was collected using a pretested, coded questionnaire. A goniometer was used to measure the active range of motion of the involved joint. The measurements were recorded in degrees. The data was analysed with STATA version 12.1.

RESULTS

58 patients were enrolled consecutively in the study. There were 36 females and 22 males, with a female to male ratio of 1.6:1. The age range was 0.75-45 years, with a median age of 5 years. The average age at the time of injury was 3.4 years. The most common cause of initial burn injury was scalding. The average number of joints involved per patient was two. There was a high incidence of recurrence of PBC (52 %) among the participants. The shoulder had the highest frequency of recurrence at 67 %. The elbow joint had a frequency of recurrence of 27 %. All participants with both elbow and shoulder joint involvement had PBC recur. The risk factors for recurrence were flame burn (p = 0.007), duration of PBC of more than 1 year (p = 0.018), and incomplete release of the contracture (p = 0.002). The presence of keloids, hypertrophic scars, ulcers and the occurrence of complications at the contracture site were not associated with recurrence of PBC.

CONCLUSION

Recurrence of PBC of the elbow and shoulder joint is a common problem. The risk factors should be kept in mind during management of PBC to reduce the recurrence rate.

Shoulder adduction contracture after burn: anatomy and treatment with quadrangular local scar subcutaneous pedicled flap, a new approach

BACKGROUND

Axillary adduction contracture is caused by scars that tightly surround the shoulder joint impairing the function of the upper limb. Due to severe scar surface deficiency, contracture release presents a challenge for surgeons since a method of release is transfer of tissue in the form of a large pedicled or free flap(s). Thus, development of simpler, less traumatic techniques, using local tissues, persists.

METHODS

Anatomic studies of shoulder adduction contractures after burn (pre-operative, during surgery, post-reconstruction) were done in 346 pediatric and adult patients. All were divided into three groups according to contracture types: with edge contractures (80%), medial (6%) and total (14%). Anatomical study covered peculiarities of total contractures and possibilities for their treatment using local scarred tissue.

RESULTS

Total contractures (48 patients) were caused by scars tightly surrounding the joint on three sides: anterior, posterior, and axillary. There were two specific forms of contracture: (a) shoulder close to the chest wall (22 of 48 patients) which was treated with thoracic pedicled or free flaps; (b) in 26 out of 48 patients a flat scar and skin graft surface laid along the shoulder and chest wall, in axillary projection, which were used for contracture release in the form of a subcutaneous pedicled quadrangular flap. The flap was mobilized only peripherally, descending to the apex of the axilla, forming the central axillary zone, and suspension of the axilla on a normal level. Wounds aside the flaps were covered with skin graft. Acceptable functional and cosmetic results were achieved in all 26 patients.

CONCLUSION

Total shoulder adduction contractures have two forms: (a) shoulder close/fused with the chest wall; and (b) along the chest wall and shoulder there is a flat surface, the tissue of which can be used for reconstruction in a form of scar subcutaneous pedicled quadrangular flap. Based on this flap, a new technique is described which is relatively easy to perform.