Classification and surgical correction of postburn axillary contractures

Management of Axillary Contracture in Poland Syndrome: Differentiating Fibrous Band and Skin for Optimal Release

Poland syndrome (PS), an uncommon congenital unilateral aplasia of chest wall muscles, may exhibit rare accompanying signs, such as axillary webbing or contractures. The existing literature on the specific management of axillary contractures is limited. In this report, we present the case of a 10-year-old girl with PS manifesting an axillary web containing a fibrous band, which was successfully surgically corrected by a double-opposing Z-plasty. Our surgical approach entailed a meticulous distinction between the deep fibrous band and the superficial cutaneous layer, guided by histopathological findings that indicated the presence of tendon-like tissue, ultimately yielding excellent outcomes. This report will help expand knowledge by highlighting the unique manifestation of PS and emphasizing the importance of employing appropriate treatment approaches. Moreover, addressing both tendon and skin components is essential for optimal contracture release in PS.

Post-burn axillary contracture: A therapeutic challenge!

Background:

Axillary post-burn scar contracture is a challenging problem to the reconstructive surgeon owing to the wide range of abduction that should be achieved. The aim of this paper was to highlight the various options used in managing axillary contractures in our hospital.

Materials and Methods:

This is a retrospective hospital-based study of axillary contractures managed at Safdarjung Hospital (a tertiary care hospital) from 2009 to 2013. The study consisted of 44 patients from all age group and both sex included in it. Patients with a bilateral axillary contracture were excluded. Axillary contracture was released and resurfaced using split skin graft and/or with different types of flaps including the propeller flap, parascapular flap. All the reconstructed cases were followed-up for a period of 12 months. Assessment was done on the basis of functional and aesthetic outcome.

Results:

Forty-four patients consisting of 25 males and 19 females presented with axillary contractures that involved 44 axillae. The mean age of the study group was 17.1 years. Injuries involved the anterior axillary fold in 8 (18.18%), posterior fold in ten (22.72%), both folds and axillary fossa in 14 (31.81%) and both folds plus part of the chest wall and arm (sparing the axillary fossa) in 12 (27.27%) axillae. Surgical treatment included split-thickness skin graft in 15 (34.1%), local skin flaps in 4 (9.1%), Z-plasties in 4 (9.1%), parascapular flaps in 3 (6.82%), while propeller flaps in 12 (27.27%) and square flap were used in 6 (13.64%) patients. The percentage of improvement in abduction had a mean of 156°. The functional and aesthetic results were satisfactory.

Conclusion:

The choice of surgical procedure for reconstruction of post-burn axillary contractures can be made according to the pattern of scar contracture and the state of the surrounding skin. The choice of a flap should have priority over the skin graft because of the superior functional and aesthetic results of flaps.

[Burn contractures of the extremities]

Burn contractures are common after deep burns of the limbs. When rehabilitation fails to restore joint function and normal range of motion, surgical contracture release should be performed. Different plastic surgery techniques can be used, from Z-plasty to skin grafts, artificial dermis and flaps. Surgery can also be used in case of esthetic concerns. Available surgical techniques and indications are presented.

Tissue expansion and latissimus dorsi transfer for arm-thorax synechia reconstruction

Inadequate treatment of severe burn injury often results in scar contractures with subsequent functional impairment and cosmetic deformities depending on the body area involved. Arm-thorax synechia is a rare but devastating complication of burns. The authors report a case of a 17-year-old boy with subtotal arm-thorax synechia, secondary to burn contracture. Reconstruction was accomplished, in two stages, with the use of tissue expanders and a latissimus dorsi muscle flap. The postoperative course was uneventful in both stages, with complete survival of both the expanded skin and the muscle flap. Early initiation of intensive rehabilitation resulted in excellent functional outcome, while significant aesthetic improvement was also ensured. In conclusion, the combined use of tissue expansion and latissimus dorsi transfer may prove to be a very good option in the treatment of complex postburn axillary contractures. The main advantages of the suggested method are the best quality of skin provided by tissue expansion and the safe coverage of any vital structures exposed with the use of the muscle flap.

Dressing of the axilla using a water-filled surgical glove after axilla grafting

Usually, after grafting of the axilla, it is difficult to obtain a reliable dressing using traditional materials including tulls and fluffy gauzes. As an alternative to this traditional approach, a sterile surgical glove filled with saline can be used to obtain a bulky dressing.

Figure-of-8 sling for prevention of recurrent axillary contracture after release and skin grafting

The axilla is a frequent site of adduction contracture after deep thermal injury, especially in burns in developing countries where the timely treatment of burns and the prevention of contracture are not possible for lack of appropriate services. Chronic contractures are difficult to treat, as large areas of wounds need to be covered with skin grafts or flaps. However, the most daunting aspect of adduction contracture is the maintenance of release after correction; this is often dealt with using long-term abduction splints, most of which are very uncomfortable. Our purpose here is to analyse our results with a simple figure-of-8 sling. A descriptive study was made covering a period of 10 years, comprising 40 cases of chronic extensive axillary contracture. All the cases were treated with simple release and skin grafting followed by a figure-of-8 sling. Preoperative limb abduction ranged from 0 degrees to 80 degrees; whereas, the postoperative range, at 1 year of follow-up, was from 140 degrees to 180 degrees. Hence, we conclude that the application of a figure-of-8 sling for axillary post-burn contractures is a safe, comfortable, easy and more compliant way of splintage with at least as reliable results as with other abduction splints.

An evaluation of functional improvement following surgical corrections of severe burn scar contracture in the axilla

This report present an evaluation 13 consecutive cases of severe burn scar contracture of the axilla and investigates the factors that influence functional improvement. The operation was performed at various times during the period from 3 months to 63 years after the initial burn wound healed. The active range of shoulder abduction before the operation in these patients was restricted to 30-90 degrees. The scar contractures in the axilla were released in all cases and the defects of the axillary region were covered with musculocutaneous flaps or fasciocutaneous flaps. Following operation rehabilitation was performed with the range of shoulder abduction had reached a plateau. The relations between the improved range of shoulder abduction, time to reach a stable range of abduction, patient age and duration of illness in each patient are discussed. Patient with long post-injury periods required a longer time to reach a stable range of abduction. Furthermore, the patients with an extremely long period before operation had difficulties such as nerve injury or stiff joint which restricted improvement. In conclusion, adequate surgical treatment in early period after occurrence of contracture is desirable for burn scar contracture of the axilla.

The index of deep burn injury: an analysis of 66 extremity sites in 15 children

The group of burn injuries generally classified as 'fourth degree' vary enormously in extent and severity. This fact, and the absence of a widely accepted grading system for these relatively uncommon injuries, has hindered our ability to learn from the experiences of others as reported in the literature. Based on a series of cadaver dissections, the Index of Deep Burn Injury (IDBI) was developed to provide such a classification scheme. The initial experience with the IDBI in a group of locally destructive "fourth degree' wounds is presented. It is believed that this index has the potential to improve our ability to describe highly destructive wounds.