Correction of post burns contracture of wrist with Ilizarov method

Treatment of Severe Postburn Contracture of the Elbow via Distraction With External Circular Frame in Pediatric Patient

BACKGROUND

Although external circular frame (ECF) has been widely used for the correction of knee and ankle deformities, few studies reported the use of ECF for the treatment of severe postburn elbow contracture and stiffness (SPECS). The purpose of this retrospective study was to investigate the effectiveness and safety of the distraction using ECF in treating SPECS.

METHODS

After institutional review board approval, we implemented a retrospective single-center case series study composed of consecutive patients treated for SPECS at Chinese PLA General Hospital between January 2010 and January 2018. After scar release and skin grafting, distraction with ECF was performed for 4 to 6 weeks, and the frame was retained for 2 more weeks before removal. Four weeks of splinting and at least 1 year of rehabilitation were recommended. Patient demographics, active and passive range of motion (ROM) of the elbow at different time points (preoperative, postdistraction, and final follow-up), and complications were collected from the electronic medical record. The primary outcome was the long-term improvement of the ROM. Other outcomes included complications and recurrence.

RESULTS

The ECF was used to treat SPECS in 6 patients (3 males and 3 females, average age of 11.7 ± 2.6 years). Scar release and distraction with ECF significantly increased both active (from 3° preoperative to 38.7° postdistraction) and passive (from 3.5° preoperative to 48.3° postdistraction) ROM over an average distraction duration of 5.2 weeks. The long-term improvement of active and passive ROM was 38° ± 13.4° and 46° ± 14.7°, respectively, over a median follow-up of 4.1 years. Pin-tract infection occurred in 2 patients and were treated with local wound care and oral antibiotics. A tendon readhesion developed in 1 of the 6 patients because of noncompliance with splinting and physiotherapy, and was treated with revision surgery.

CONCLUSIONS

The 3C strategy (i.e., contracture release, coverage of the defect with skin grafting, and correction of articular angle with gradual distraction using the ECF) is able to increase the ROM with minor complications. We recommend distraction with ECF as part of the treatment arsenal, particularly for severe contractures in which 1-stage correction is unfeasible because of considerable soft tissue shortening.

Efficacy of inpatient burn rehabilitation: a prospective pilot study examining range of motion, hand function and balance

PURPOSE

To examine the effect of inpatient rehabilitation therapy on range of motion, hand function and balance in the burn population.

METHODS

This study utilizes a prospective longitudinal design. Inclusion criteria are adults admitted to a regional inpatient rehabilitation hospital with a primary diagnosis of burn injury. Demographic and medical data are collected. Primary outcomes include range of motion at four joints (shoulder, elbow, hip, knee), hand function (Jebsen Taylor Hand Test) and balance (Berg Balance Scale). Outcomes are measured at admission and discharge. Students't-test is used to determine significant differences in outcomes from admission to discharge.

RESULTS

Eleven subjects meet inclusion criteria. The mean age is 50 years, rehabilitation length of stay is 35 days and total body surface area burned is 41%. Subjects demonstrate significant improvements in range of motion, hand function and balance from admission to discharge (p<0.05).

CONCLUSIONS

Specific functional measures, range of motion, hand function and balance, demonstrate significant improvement during inpatient rehabilitation. Future work is needed to investigate other functional benefits of rehabilitation and to compare the impact of inpatient rehabilitation to other therapeutic interventions.

Management of postburn contractures of the upper extremity

Postburn contractures of the upper extremity are better prevented than treated, but many patients still suffer from this disability, especially after suboptimal primary care or major burns. Principles applicable to release of postburn contractures of the upper extremity are discussed, with a joint-specific review of relevant techniques to accomplish the release of the contracture. Pre- and postoperative care is discussed.

The use of external skeletal fixation to facilitate the surgical release of wrist flexion and thumb web space contractures

PURPOSE

To evaluate the use of external fixation as a splint to keep the hand in the desired position after simultaneous joint and soft-tissue release in a single stage for treatment of first web space and wrist contractures.

METHODS

Six first web space adduction and 7 wrist flexion contractures were released surgically. All patients had prior unsuccessful surgery. After surgical release of the contracture and capsulotomy, external fixator pins were inserted into the first and second metacarpals to maintain thumb abduction and into the radius and second metacarpal to maintain wrist extension, followed by skin grafting. External fixation was followed by splinting. Results were based on persistence of contracture release, rate of complications, and functional outcome.

RESULTS

Before surgery, the thumbs were contracted at an average of 0 degrees of adduction with no range of motion, and wrists were contracted between 85 degrees to 100 degrees of flexion. The duration of contracture and number of prior surgeries did not influence the amount of release obtained during the surgery. After 7 months to 7 years of follow-up of first web space contractures, the thumb was in an average of 55 degrees of palmar abduction. Patients were able to oppose and fully adduct. At long-term follow-up examinations of the wrist contractures, patients had the wrist in the neutral position (0 degrees) in the resting state, with active extension ranging between 5 degrees and 15 degrees and flexion ranging between 35 degrees and 45 degrees . In 1 patient the wrist was at 45 degrees of flexion in the resting state with an arc of motion of 20 degrees . In 1 patient the wrist contracted back to the preoperative position, requiring another surgery. All patients experienced increased activity and improvement in grasping objects at 6-month follow-up evaluations. Complications included 3 pin site infections, 1 severe discomfort after 6 weeks, and 1 median nerve compression. All were treated successfully.

CONCLUSIONS

External fixation can be used to maintain position in cases of first web space and wrist flexion contractures after surgical release, especially in patients for whom standard methods have failed. It is safe, efficacious, and well tolerated.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Treatment of flexion contractures following burns in extremities

In order to release and cover defects in burn contractures over joints, several surgical procedures have been proposed. Skin grafting is easy to do, but it requires immobilization, and tends to contract again, different types of flaps without skin grafting are alternatives. These flaps have their specific indications, limitations and some disadvantages such as a bulky, unattractive appearance in donor or recipient sites, partial necrosis, and sometimes patients dissatisfaction. Considering these points, the authors proposed a new technique composed of a Y-V advancement in the middle and two scar releases proximal and distal to the joint which were covered with full thickness skin grafts. This seems to have some advantages in both case of technique and more patients satisfaction. In the current study, the authors presented their results with different methods of treatment, which they performed for burn flexion contractures in limbs. Ninety-one operations were performed in 74 patients, the method of reconstruction included skin grafting in 43 contractures, local flaps in 16, pediculated flaps in 11, and the new combined approach in 21 cases. Width of scar was one of the main factors for selection of choice option. This proposed technique is especially appropriate for scars which cover 10-60% of joint surface area. Advantages of this combined technique are coverage of joint area with a pretty normal skin flap, and enough scar lengthening due to combination of Y-V advancement and skin grafted released areas.

Contractures in burn injury: defining the problem

This study prospectively examined the incidence and severity of large joint contractures after burn injury and determined predictors of contracture development. Data were collected prospectively from 1993 to 2002 for consecutive adult burn survivors admitted to a regional burn center. Demographic and medical data were collected on each subject. The primary outcome measures included the presence of contractures, number of contractures per patient, and severity of contractures at each of four joints (shoulder, elbow, hip, knee) at time of hospital discharge. Logistic regression analysis was performed to determine predictors of the presence and severity of contractures and a negative binomial regression was performed to determine predictors of the number of contractures. Of the 985 study patients, 381 (38.7%) developed at least one contracture at hospital discharge. Among those with at least one contracture, the mean is three contractures per person. The shoulder was the most frequently contracted joint (38%), followed by the elbow (34%) and knee (22%). Most contractures were mild (60%) or moderate (32%) in severity. Statistically significant predictors of contracture development were length of stay (P < .005) and extent of burn (P = .033) and graft (P < .005). Predictors of the severity of contracture include graft size (P < .005), amputation (P = .034), and inhalation injury (P = .036). More than one third of the patients with a major burn injury developed a contracture at hospital discharge, which highlights the importance of therapeutic positioning and intensive therapy intervention during acute hospitalization. Furthermore, this challenges the burn care community to find new and better ways of preventing contractures after burn injury.

Use of Joshi External Stabilizing System in Postburn Contractures of the Hand and Wrist: A 20-Year Experience

Postburn contractures of the hand and wrist can range from a minor cosmetic problem to a crippling condition. The contractures, initially limited to the skin, extend to all the soft-tissue structures over time, often necessitating capsulotomies and tendon lengthening, although they still may not be amenable to total correction. The Joshi External Stabilizing System (JESS) is a versatile, lightweight external fixator consisting of K wires, distractors, and connecting rods (both hinged and nonhinged) along with various link joints. JESS is a dynamic system that allows the lengthening of the contracted tissues via slow distraction, causing minimal surgical insult. This is a retrospective review of 218 cases of postburn contractures of the hand treated with JESS during the last 20 years. Deformities varied from finger contractures to metacarpophalangeal joint and wrist contractures. All cases were of long duration at the time of presentation with the original injury being 4 months to 20 years old. All were assessed for the degree of function and deformity. The patients' activities of daily living were recorded and x-rays taken to evaluate joint configuration. The patients underwent a conservative surgical release followed by application of the appropriate JESS frame for the correction of the residual deformity. After 6 weeks, the frame was removed and hand therapy continued. An analysis is provided of the outcome. The technique produces functional hands with minimal surgical insult.

Management of An Unusual Extreme Extension Contracture of the Wrist

An extreme extension contracture of wrist with dorsal contracture of fingers 15 years after burn injury is described. Shortening of extensor tendons, secondary lengthening of flexor tendons, contracted wrist joint capsule, unusual dislocation of carpals, dorsal dislocation of metacarpophalangeal joints of fingers, and provision of sufficient amount of good-quality skin were some of the issues that had to be addressed in treatment. The contracture was released, the carpals and metacarpophalangeal joint dislocations were corrected and fixed with K wires, and the resulting defect was covered with a sheet split-thickness skin graft. An exercise program was designed that consisted of isotonic, isokinetic, and isometric resistance exercises and passive, active, and active-assistive range of motion exercises. These exercises were pursued with the intention of increasing dynamic strength, endurance, and overall functional recovery of the flexor muscles by exploiting the immature nature of early scar tissue. The resultant enhanced flexor muscle power from exercises along with the dynamic splint helped in lengthening of extensor tendons, wrist joint capsule, and split-thickness skin graft. It also helped in resisting the recontracting tendency, with further recovery of good range of wrist and fingers movements, obviating the need of tendon-lengthening surgery and flap coverage. One and half years of follow up didn't show any sign of recontracture, and the patient was able to perform his routine activities. Postburn wrist contractures of such magnitude have been seldom described. Emphasis is put on simple contracture release and a postoperative exercise program.