Annals of Burns and Fire Disasters - vol. XIII - n° 1 - March 2000

TREATMENT OF POST-BURN DEFECTS IN THE UPPER MEMBER

Martinez-Sahuquillo Marquez J.M., Jimenez Còrdoba G., Martinez-Sahuquillo A.

Department of Plastic Surgery and Burns, Virgen Macarena University Hospital, Seville, Spain

SUMMARY. Defects in the burned upper member vary in relation to the following factors: the severity of the burn, inadequate management, and general or local complications. Accurate treatment can reduce the impact of the defects. Injuries in the joints, the arms, and the hands are considered. Various combinations of injuries are also described. The successive steps in the reconstruction process are presented.

The upper member is of great importance as it holds and sustains the hand, which is - after the brain - our body's most perceptive organ.
The hand and the arm are a physiological kinetic unit, joined together functionally, biologically, and mechanically from the fingertips to the shoulder - hence the functional and aesthetic importance of the correction of defects in the upper member in order to recover the normal mobility of its joints as well as its appearance.
Burn-related defects in the upper member vary as a function of the following factors:

• the severity of the burn - except in the case of firstdegree bums, there is always some functional or aesthetic defect, however well they have been treated
• inadequate management of the burn
• general or local complications of the burn

These defects can be minimized by appropriate management. This includes early removal of scars, the use of free skin grafts to cover affected areas, accurate positioning of the member, active and passive rehabilitation, the use of Job compressive garments, and the careful monitoring of treatment during the acute phase of the bum.
The treatment of post-burn defects involves surgery as well as rehabilitation. Surgery aims at repairing damaged structures. In general tenns this phase should begin as soon as possible - ideally when the scars are stabilized, which usually occurs between 6 and 24 months post-trauma. It is however advisable to operate earlier in the case of growing children, whose joints suffer great stress and may be displaced, and in whom the defect is still expanding and may affect functionality. During this period of time, the joints should be moved active and passively; continuous pressure should be exercised on the skin tissue, and topical or intra-intestinal cortisone should be prescribed.
In general, and before treatment of the bum, all elements that have been affected, especially those involving joints and the hand, should be clinically and radiologically examined in order to assess the state of the muscles, tendons, blood vessels, and nerves. This provides thorough knowledge of the elements that have to be repaired and helps to establish the most appropriate management plan.
Before any attempt is made to repair the defects, the surface and the deeper layers of the scarred tissue must be removed, the vital elements must be freed, and a generous area of skin next to the defect must be lifted in order to evaluate the actual loss of tissue and the elements that need to be repaired. Haemostasis must be meticulous and the retraction of the vital elements, as also manipulation of the joints. must be performed with utmost care in order to prevent further damage.
To repair loss of skin in joint areas, it is advisable to use free skin grafts and skin flaps (Figs. 1, 2).

If possible, flexible skin should be used for placement on the deep planes, in order to avoid secondary retractions. It should be sufficiently cushioned to withstand pressure and scratches and to allow further interventions. These features can be found only in skin flaps and in some free skin grafts. Free skin grafts should not however be used when the removal of scar tissue would expose vital elements such as nerves, blood vessels, and tendons, a not infrequent occurrence in the arrnpits and flexible areas of the elbow and the back of the hand. Another advantage of using flaps is their optimal elasticity, which allows total recovery of active and passive joint movements with adequate post-surgical rehabilitation - there are no limitations from the cutaneous point of view.
Regarding the techniques used to repair the cutaneous cover, the only limitations on the management of these conditions are basically the size, depth, and location of the defect and the state of the adjacent tissue. The easiest procedure must always be used: removal and direct suture; free skin grafts; and adjacent, distant, fasciocutancous, myocutancous, and free skin flaps.
Owing to the anatomical and functional characteristics of the different areas of the upper member, we have classified post-burn injuries following Mir y Mir: in the joints, in both arms, and in the hands.

Injuries in the joints and in both arms
The correction of injuries in the armpit, elbow, and wrist is of great importance owing to the functional disabilities they may cause. Injuries in the armpit may lead to inadequate abduction, elevation, ante-position, and retrocession of the arm, thus limiting hand mobility. Injuries in the elbow and the wrist impede flexor extension and pronation of the forearm and hand. When bums in the upper member affect the armpit or its anterior surface they cause retractions or contractions (Fig. 3).

Fig. 3a - Retractile scar on anterior side of arm Fig. 3b - Repair with local flaps Fig. 3c - Result one yr later

When they affect the posterior surface they cause chronic ulcerations in the acromion and the olecranon, adherence to tendons near the wrist and the back of the hand, and the lack-of-skin syndrome. Defects in isolated areas of the shoulder and in the arm and forearm indirectly affect the joint areas, hindering normal functioning. The elbow is considered to be the most likely area for post-burn heterotopic calcifications.
These consequences range from simple lineal retractile scars that affect normal functioning of the joint to large contractions that interfere with movements of the joints or are distiguring.
For lineal retractions we use skin flaps, chiefly simple or multiple Z-plasties. These are easy to implement and provide tissue similar to the tissue we wish to correct, the scar is less visible, and the operation can performed rapidly. Its only inconvenience is its indications. The combination of flaps and free skin grafts succeeds in solving most joint contraction problems (Fig. 4).

We use free skin grafts to repair defects in both arms, for large branchiothorax retractions, for those located on the extension surfaces of the joints and the back of the hand, and for those located in scarred surfaces in the flexion areas where no vital elements are exposed. Free skin grafts have the disadvantage of causing secondary retraction, thus necessitating protracted immobilization if performed in a flexion area.
If vital elements are exposed, we use adjacent skin flaps, either alone or combined with free skin grafts or distant flaps. For retractions affecting the neck, arm, and thorax in which a large scar joins the arm to the neck and thorax, once the sear has been removed we repair the area using skin grafts and branchial flaps and the lateral thorax with the upper pedicle. These defects can now be repaired with scapular and parascapular fasciocutaneous flaps - mainly the latter as they are longer and can provide more tissue.
The hypogastric flap irrigated by the tipper epigastric artery is very mobile, which makes it very useful for repairing defects on the front and back surfaces of the elbow (Figs. 5, 6).

Injuries in the hands
The repair of post-burn defects in the hand is a challenge for the plastic surgeon, not only because of the difficulties involved in the reconstruction itself but also considering how rewarding reconstruction is for the patient. Bums are perhaps the greatest of physiological tragedies for the professional and functional development. of the individual with regard not only to the person's working activity but also to the more social and intimate sphere. Any defect in this field can cause important psychological problems that may give rise to psychopathies affecting the individual's mental and emotional integrity and creating economic and social disorders.
Owing to the numerous elements that can be involved, it is difficult to classify post-burn injuries in the hands. For simplicity's sake, it can be said that burns affecting the anterior surface of the hand affect only its surface, the subcutaneous cell tissue, and the aponeurosis because of the thickness of the skin in this area, and cause retraction in the palm of the hands and the fingers, with retractile interdiggital scars (Fig. 7).

In more severe cases there can be claw-hand, club-hand, and total or partial amputation. Burns on the back of the hand can affect the tendons with luxations in the interphalangeal joints of the fingers.
There can be other different combinations, such as the presence of some fingers in flexion and others in extension, as well as total or partial amputation, longitudinal scar band, traumatic syndactylies caused by interdigital scars, mainly in the proximal phalanges, joint deformities, painful scars in the finger tips, ectopia of the fingers, adherences and tendon rupture (especially in the extensors and rarely in the flexors), carpal tunnel syndrome, corns and deformities in the nails, etc. Before repairing any such lesions, it is essential to know the state of the skin, tendons, joints, vessels, and nerves (Fig. 8).

It is also very useful to assess the mobility of the joints and to carry out x-rays and bone tomographies, vascular studies, and electromyograms, as all these procedures provide a general idea of the elements needing to be repaired and help to prepare the most appropriate plan. In most cases, more than one surgical intervention will be necessary.
The first step is to reconstruct the cutaneous layers. If the scar contracture is immature, it is advisable to use compressive dressings. If the scar contracture is stabilized, surgery is the alternative, using the techniques mentioned.
To reconstruct defects in the tendons, joints, and other elements, it is indispensable to have a good cutaneous layer (Fig. 9).

Fig. 9a, b - Thumb adhering to palm of hand with loss of first commissure. Total liberation of thumb and repair of palm and anterior surface of finger with groin flap.

The techniques used to repair the skin depend on the size and depth of the wounds. We use Z-plasties to treat retractile scar bands, free skin grafts (preferably full or three-quarters thickness), and skin flaps. The groin flap, irrigated by the superficial iliac artery, is very suitable for reconstructing defects in the hand as it provides a great deal of thin skin and is very versatile. The following procedures are also recommended: Z-plasty combined with skin grafts, simple island flaps, neurovascular pedicular island flaps, and free flaps.
Tenotomies, osteotomies, arthrodesis, sutures, tendon and nerve transplants, amputations, etc., along with dynamic splints, compression and, above all, adequate rehabilitation enable us to obtain functional solutions for various severe post-burn defects that affect the elements of the hand.

RESUME. Les défauts du membre supérieur brûlé varient selon les facteurs suivants: la sévérité de la brûlure, la gestion inadéquate, et les complications générales et locales. Un traitement soigné peut réduire l'effet des défauts. Les Auteurs considèrent les lésions des articulations des bras et des mains. Ils considèrent en outre diverses combinations des lésions. Les phases successives du procès de reconstruction sont présentées.