Postburn Contractures of the Hand

Optimizing Outcomes in the Management of the Burned Hand

Burns of the hand are prevalent and must be managed aggressively in the acute phase to prevent deformity and disability. Proper early wound management, achieving durable soft tissue coverage, and appropriate positioning in the acute period offer substantial benefits to patients long-term. When contractures occur, secondary procedures are often indicated, and they range from laser therapy to local/regional flap coverage; rarely free flaps are used. Boutonniere deformities are common, and unfortunately, at times finger amputation renders the hand more functional than further efforts at reconstruction.

Acute and Reconstructive Burn Care of the Hand

The hand is commonly affected in thermal injuries. Hand burns account for 39% of all burns and they are involved in 34% of instances when the total body surface area of a burn exceeds 15%. Inadequate or inappropriate treatment could result in significant morbidity. The ultimate integration of a burn patient into the society largely depends on the functionality of the hands. Hence, it is important to reduce complications by providing good care during the acute stage.

Management of Scar Contractures of the Hand-Our Therapeutic Strategy and Challenges

The essence of treating scar contractures lies in covering the skin deficit after releasing the contractures, typically using flaps or skin grafts. However, the specific characteristics of scar contractures, such as their location, shape, and size, vary among patients, which makes surgical planning challenging. To achieve excellent outcomes in the treatment of scar contractures, we have developed a dimensional classification system for these contractures. This system categorizes them into four types: type 1 (superficial linear), type 2-d (deep linear), type 2-s (planar scar contractures confined to the superficial layer), and type 3 (planar scar contractures that reach the deep layer, i.e., three-dimensional scar contractures). Additionally, three factors should be considered when determining surgical approaches: the size of the defect, the availability of healthy skin around the defect, and the blood circulation in the defect bed. Type 1 and type 2-d are linear scars; thus, the scar is excised and sutured in a straight line, and the contracture is released using z-plasty or its modified methods. For type 2-s, after releasing the scar contracture band, local flaps are indicated for small defects, pedicled perforator flaps for medium defects, and free flaps and distant flaps for large defects. Type 2-s has good blood circulation in the defect bed, so full-thickness skin grafting is also a suitable option regardless of the defect's size. In type 3, releasing the deep scar contracture will expose important structures with poor blood circulation, such as tendons, joints, and bones. Thus, a surgical plan using flaps, rather than skin grafts, is recommended. A severity classification and treatment strategy for scar contractures have not yet been established. By objectively classifying and quantifying scar contractures, we believe that better treatment outcomes can be achieved.

Effect of exoskeleton manipulator on hand function rehabilitation for postburn patients

PURPOSE

Patients with scar contracture deformities caused by hand burns were treated with an exoskeleton manipulator system, which was equipped with games to explore its clinical application value.

METHODS

Twenty patients who were treated for post-burn scars of bilateral hands between October 2020 and June 2021 were selected (ChiCTR2000036232). The patients were divided into two groups: control, 10 patients (traditional outpatient treatment); and experimental, 10 patients (exoskeleton manipulator system treatment). We compared the change in the total active motion (TAM) value, grip strength, scar improvement, and postoperative pain improvement.

RESULTS

After 3 months of rehabilitation training, the improvement of thumb TAM was 33.80 ± 11.38 ° in the experimental group and 23.2 ± 6.13 ° in the control group. With respect to the index finger TAM, the improvement in the experimental and control groups was 84.50 ± 30.96 ° and 54.80 ± 15.89 °, respectively. The middle finger TAM of the experimental and control groups improved by 86.75 ± 32.85 ° and 60.25 ± 17.97 °, respectively. However, improvement of grip strength, scar score, and pain score were similar between the two groups.

CONCLUSIONS

The exoskeleton manipulator system has excellent effects in improving burned hand joint movement, which is suitable for hand burn patients and has beneficial clinical effects.Implications for rehabilitationExercise is an effective means to improve the hand function of burn patients.The application of mechanical devices in the rehabilitation of burned hands can effectively help patients exercise.The A5 Hand Function Training System is an exoskeleton mechanical device that can exercise the small joints of the hand. It assists patients in using different computer games during treatment.

Holistic Approach to Burn Reconstruction and Scar Rehabilitation

More than 11 million burn injuries occur each year across the world. Many people with burn injuries, regardless of injury size, develop hypertrophic scar, contracture, unstable scar, heterotopic ossification, and disability resulting from these sequelae. Advances in trauma systems, critical care, safe surgery, and multidisciplinary burn care have markedly improved the survival of people who have experienced extensive burn injuries. Burn scar reconstruction aims to improve or restore physical function, confidence, and body image. Like acute burn care, burn scar reconstruction requires thoughtful, coordinated approaches along the continuum of burn injury, recovery, and rehabilitation.

Functional and aesthetic outcomes of abdominal full-thickness skin grafts in paediatric postburn digital and palmar flexion contractures

The study aimed to assess the functional and aesthetic outcomes of abdominal full-thickness skin grafts (FTSGs) in paediatric postburn digital and palmar flexion contractures. The digital and palmar functions and aesthetics of 50 children who met the criteria were evaluated at pre-operation, the 3rd- and 12th-month post-operation, respectively. In the evaluation, the Vancouver Scar Scale (VSS), total active movement (TAM), and Jebsen-Taylor Hand Function Test (JHFT) were used. The contralateral, unaffected hand served as the criteria for functional recovery. The complications of donor sites were observed, and the take rate of skin grafts was calculated. The VSS scores at the 3rd and 12th months post-operation were lower than those before the operation. The TAM of each finger was improved at the 3rd and 12th months post-operation, compared with that before the operation. There was a significant difference in the time to complete the JHFT between the affected hand and the unaffected at the 3rd month post-operation, but no significant difference between them at the 12th month post-operation. The excellent and good take rate of the skin grafts was 90.00%.No donor site complications were observed. The abdominal FTSGs are effective in repairing paediatric digital and palmar scar contractures, with satisfying functional and aesthetic results, especially in large defects after scar release and resection.

Comparison Study of 5-flap Z-Plasty and Double Z-Plasty for Interdigital Pocket Web Contractures

PURPOSE

The aim of this study was to compare the improvement in abduction and change in web slope between 5-flap z-plasty and double z-plasty for post-burn or post-trauma interdigital pocket web contractures.

METHODS

We retrospectively reviewed 16 webs in 11 patients with post-burn or post-trauma interdigital pocket web contractures. Seven patients underwent 5-flap z-plasty and 4 double z-plasty. The abduction and slope angles of the affected fingers were measured before surgery and every 3 months after surgery.

RESULTS

The follow-up time ranged from 12 to 36 months. The postoperative abduction angle improved in both groups. There was an increase of 19° ± 4° in the mean abduction angle after surgery in the 5-flap z-plasty group compared with a mean of 12° ± 2° in the double z-plasty group; the postoperative decrease in the web slope angle was 30° ± 5° and 22° ± 2°, respectively. All patients were able to actively move the affected webs and fingers with no pain or other discomfort.

CONCLUSIONS

Five-flap z-plasty can be considered a better alternative to double z-plasty for interdigital pocket web contractures based on the improvement in abduction angle and changes in the slope angle.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

A Challenging Case of Using Manta Ray Skin Flaps in a Severe Post-Traumatic First Web Space Contracture

Patient: Male, 36-year-old

Final Diagnosis: Web space contracture

Symptoms: Joint stiffnes • loss of thumb abduction • severe scarring

Medication: —

Clinical Procedure: Contracture release

Specialty: Orthopedics and Traumatology • Plastic Surgery

Expanding indication of free hypothenar flap transfer: Sequential pedicled ulnar palm flap transfer to a relatively large hypothenar flap donor site

BACKGROUND

Free hypothenar flap (HTF) transfer allows sensible soft tissue reconstruction of the fingertip. However, HTF is basically indicated for a relatively small soft tissue defect, as width of an HTF is limited up to approximately 20 mm to allow primary donor site closure. Combined with sequential local flap to an HTF donor site, a larger HTF can be used without the contracture risk. The aim of this study was to evaluate feasibility of free HTF transfer and sequential ulnar palm flap (UPF) transfer (HTF-UPF) for relatively large fingertip reconstructions.

METHODS

Medical charts of patients who underwent HTF-UPF for fingertip reconstruction were reviewed. An HTF was designed transversely proximal to the proximal palmar crease, and a slightly smaller hemi-spindle-shaped UPF was designed longitudinally on the mid-lateral aspect of the ulnar palm; the UPF was used to close the HTF donor site. Patient and flap characteristics, intra-operative findings, and postoperative results were evaluated.

RESULTS

Twelve patients with average age of 42.7 years were included. HTF-UPF procedure was performed on 12 fingers. HTF's length/width ranged from 45/20 to 70/40 mm (average, 52.5/32.1 mm). UPF's length/width ranged from 40/20 to 55/30 mm (average, 46.7/24.2 mm). Time for sequential UPF transfer ranged from 3 to 9 min (average, 5.1 min). All HTFs and UPFs survived without flap necrosis or scar contracture. Postoperative sensation was comparable with the contralateral fingertip.

CONCLUSIONS

HTF-UPF procedure allows relatively large fingertip reconstruction with a minimum risk of HTF donor site contracture.

Diverse cellular players orchestrate regeneration after wounding

Fibrosis is one of the largest sources of human morbidity. The skin is a complex organ where interplay between diverse cell types and signalling pathways is essential both in homeostasis and wound repair, which can result in fibrosis or regeneration. This makes skin a useful model to study fibrosis and regeneration. While fibrosis often occurs postinjury, both clinical and laboratory observations suggest skin regeneration, complete with reconstituted cell diversity and de novo hair follicles, is possible. Extensive research performed in pursuit of skin regeneration has elucidated the key players, both cellular and molecular. Interestingly, some cells known for their homeostatic function are not implicated in regeneration or wound-induced hair neogenesis (WIHN), suggesting regeneration harnesses separate functional pathways from embryogenesis or other non-homeostatic mechanisms. For example, classic bulge cells, noted for their role in normally cycling hair follicles, do not finally contribute to long-lived cells in the regenerated tissue. During healing, multiple populations of cells, among them specific epithelial lineages, mesenchymal cells, and immune cells promote regenerative outcomes in the wounded skin. Ultimately, targeting specific populations of cells will be essential in manipulating a postwound environment to favour regeneration in lieu of fibrosis.

Surgically Treated Pediatric Hand and Fingers Palmar Wounds Caused by Metal Fences: Analysis Over a 5-Year Period

BACKGROUND

Hand wounds are frequent in children (31% of hand injuries) and one possible mechanism responsible for profound laceration is metal fences while climbing. These injuries usually require a surgical look to explore soft-tissue damages, but the literature is poor regarding surgical findings and outcomes after this kind of traumatism. The aim of the study was therefore to report a consecutive series of hand and finger wounds caused by metal fences in children, focusing on surgical findings and potential complications.

METHODS

All consecutive hand or finger deep wounds caused by metal fences treated between January 2013 and December 2018 were retrospectively reviewed. Inclusion criteria were age below 18 years and a minimum follow-up of 2 years. Complications and surgical revisions were analyzed.

RESULTS

A total of 1265 patients were operated for hand or finger deep wounds during the study period, among which 74 were caused by metal fences. The mean age at surgery was 11.3±0.4 years, and the majority of patients were men (80%). Associated injuries were found in 55.4% of the patients including nerves (n=29) or tendons sections/disinsertion (n=6), and sheath (n=16) and pulleys (n=6) tearing. At a mean follow-up of 2.6±0.2 years, 12% of the patients required revision surgery for an irreducible flexion contracture secondary to a contractile scar and consisted of complete scar excision and zigzag flap. Additional tenoarthrolysis was required during the procedure, for 6 patients because of a persisting flexion contracture after excision.

CONCLUSIONS

Metal fences surgical palmar wounds in children are impressive lesions by their extended skin damages. Serious associated lesions (collateral pedicle or flexor tendons) were found in 1 case of 3. However, these injuries are not benign and should be carefully monitored clinically during the first postoperative month to look for potential contractile scars that can require revision.

LEVEL OF EVIDENCE

Level IV-retrospective cohort study.

Concepts in Early Reconstruction of the Burned Hand

BACKGROUND

Early reconstruction of burn sequelae of the hand can be challenging owing to high goals for functional and aesthetic outcome. A variety of reconstructive procedures with ascending levels of complexity exists and warrants careful indication.

METHODS

In this case series, the main reconstructive techniques for reconstruction of burn defects of the hand are described, illustrated, and discussed: split thickness skin grafting (STSG) with fibrin glue, dermal matrices with STSG, distant random pattern (abdominal bridge) flap, distant pedicled flap (superficial circumflex iliac artery flap), and free microvascular tissue transfer (anterolateral thigh flap). An algorithm for decision making in the reconstructive process is proposed.

RESULTS

Split thickness skin grafting provides sufficient coverage for partial thickness defects without exposure of functional structures; fixation with fibrin glue avoids unnecessary stapling. Dermal matrices under STSG provide vascularized granulation tissue on full thickness defects and can be used as salvage procedure on functional structures. Distant random pattern or pedicled flaps provide sufficient coverage of large full thickness defects with exposed functional structures but pose some challenges regarding patient compliance and immobilization. Free tissue transfer allows tailored reconstruction of large full thickness defects with exposed functional structures and can be safely and feasibly performed. Secondary and tertiary procedures are needed with more complex techniques; if applied correctly and consequently, all methods can yield favorable functional and aesthetic outcomes.

CONCLUSIONS

Reconstruction of the burned hand may require a broad armamentarium of surgical techniques with different levels of complexity, versatility, and applicability. Excellent results can be achieved with the right procedure for the right patient.

Postoperative Management of Hand Surgery in the Low- and Middle-Income Countries

The prevention and treatment of hand injuries in low- to middle-income countries needs to be a priority. Surgical outreach trips are a primary avenue for patients to receive interventions. Challenges include language and cultural barriers, poor infrastructure, and limitations in a patient's ability to follow-up. Strategies to maximize patient functional outcomes include cultural competence, patient education resources, overcoming communication barriers, and using task-shifting strategies. Local therapists' knowledge and clinical skills can be enhanced. With improvements in data collection, therapists may contribute to gaining knowledge of outcomes in low- to middle-income countries.

[Clinical application of thoracodorsal artery perforator flap in repair of serious scar contracture of opisthenar]

OBJECTIVE

To investigate the feasibility and effectiveness of thoracodorsal artery perforator (TDAP) flap for repairing serious scar contracture of the opisthenar.

METHODS

Between March 2015 and June 2017, 7 cases of serious scar contracture of opisthenar were repaired with TDAP flaps. There were 5 males and 2 females with an average age of 31 years (range, 11-48 years). The time from injury to operation was 8-67 months, with an average of 42 months. After the relocation of the joint and release of the scar, the size of soft tissue defect ranged from 5 cm×4 cm to 10 cm×8 cm. The size of TDAP flap ranged from 5.5 cm×5.0 cm to 10.5 cm×9.0 cm.

RESULTS

All flaps survived completely with primary healing at both donor site and recipient site. The flaps of 3 patients were bulky and underwent second-stage skin flap thinning at 3 months after operation. All 7 patients were followed up 6-32 months, with an average of 15 months. The skin flaps were soft and elastic. According to the upper limb function evaluation system recommended by Chinese Society of Hand Surgery, sensory function was classified as S3+ in 2 cases, S3+ in 1 case, S2+ in 3 cases, and S11+ in 1 case. The hand function was excellent in 2 cases, good in 4 cases, and fair in 1 case. There was no significant effect on shoulder movement.

CONCLUSION

The TDAP flap is an ideal method for serious scar contracture of opisthenar.

Dorsal pentagonal island flap to reconstruct post-burn interdigital web

INTRODUCTION

This study reports the use of a dorsal pentagonal island flap for post-burn webbing contracture, in which the islanded flap is harvested from the burn scar tissue.

METHODS

Fourteen dorsal pentagonal island flaps were harvested in seven patients with post-burn webbing. Each flap was selected by examining the scar tissue donor using a modified Vancouver scar scale. Modification from the basic design was made according to the density of the donor scar tissue and the metacarpophalangeal joint movement.

RESULTS

All the flaps survived with normal abduction of the affected fingers. Modification of the flap design needed adjustment by assessing it through flexion and extension of the metacarpophalangeal joints. There was no incidence of web creep after two months to one year of follow-up.

CONCLUSION

Dorsal pentagonal island flap shows promising results as an alternative for reconstructing post-burn webbing.

The Application of Three-Dimensional Printed Finger Splints for Post Hand Burn Patients: A Case Series Investigation

The application of three-dimensional (3D) printing is growing explosively in the medical field, and is especially widespread in the clinical use of fabricating upper limb orthosis and prosthesis. Advantages of 3D-printed orthosis compared to conventional ones include its lower cost, easier modification, and faster fabrication. Hands are the most common body parts involved with burn victims and one of the main complications of hand burns are finger joint contractures. Applying orthotic devices such as finger splints are a well-established essential element of burn care. In spite of the rapid evolution of the clinical use of 3D printing, to our knowledge, its application to hand burn patients has not yet been reported. In this study, the authors present a series of patients with hand burn injuries whose orthotic needs were fulfilled with the application of 3D-printed finger splints.

Electrical Burns and Their Treatment in a Tertiary Hospital in Albania

INTRODUCTION:

The electrical current burns represent a very aggressive pathology that leaves many functional and aesthetic consequences.

AIM:

To evaluate the epidemiology of electrical burn injury and its associated complications and treatment.

MATERIAL AND METHODS:

Demographic data, aetiology, burn percentage and other measures related to electrical burn injury of 33 electrical burn patients in a tertiary hospital during the years 2015-2017.

RESULTS:

The mean age of patients is 31 (± 8.3) years old with a predominance of males (94%). The vast majority of injuries occurred at work (p < 0.01), superior extremities were more affected with hand (21.2%) and fingers (18.2%) being the main point of contact (p < 0.01). Muscular fasciotomy was performed in all patients who were treated surgically (n = 27), amputation was performed in 11 (40.7%) of cases, but amputated sites were more than the number of patients affected. Myoglobinuria (39.4%), cardio-respiratory distress (12.1%) contusion cerebri (6.1%), were the complication encountered in patients.

CONCLUSIONS:

Electrical burn injuries are still amongst the highest accident-related morbidities. Educating the population about the dangers and hazards associated with improper use of electrical devices and instruments is imperative.

Epidemiology of Hand Burn in Albania 2011-2016

INTRODUCTION

Hand burns occur commonly both as part of larger burn injuries as well as isolated injuries.

AIM

To give an overview of epidemiologic features and outcome of burn hand patients who admitted to our Service. This study was performed at University Hospital Center "Mother Teresa" Tirana which is the only tertiary hospital in Albania.

MATERIAL AND METHODS

This prospective study included all patients who had combustion of the hands solely or hands accompanied with burns to other areas of the body, treated and followed up at our service during the years 2011-2016.

RESULTS

Of the 333 included burn patients, 64% were males. The median age of patients is 25.9 years. About half of patients belong to the age group 20-60 years (49.5%) and only 10.2% belong to the age of 60 years. In most of the cases (73.6%), the burn of hands is associated with the burn of the other anatomical region, mostly forearm.

CONCLUSION

The surgical treatment is used for less 30% that of patients. The undesirable results of the burn of hands are presented in the 33% of the patients. The contractures were the main unfavourable outcome of the burned hand.