Annals of the MBC - vol. 3 - n' 1 - March 1990

SURGICAL TREATMENT OF POST-BURN CONTRACTURES OF THE HAND

Caleffi E., Bocchi A., Toschi S., Ghillani M.

Divisione di Chirurgia Plastica, Parma, Italia

SUMMARY. When static and dynamic splints fail to improve the functional and aesthetic outcome of post-burn contractures of the hand, surgery is often found to be necessary. The only surgical procedure that offers satisfactory results is the flap technique. Three case histories are described.

In post-bum contractures of the hand surgical treatment is often necessary when prevention by means of splints has failed to improve the functional or aesthetic outcome. According to Tajinia (1), corrective splints can be classified in two types: static and dynamic.
The former exert a self-controlled corrective force on joint stitTness; dynamic splints exert a constant corrective force by the elasticity of a rubber band or wire spring. Improvement with corrective splinting is usually remarkable in the first two weeks and then gradually slows down in a month or two. However, splintage should be continued until there is no further improvement (2, 3). In our experience there are several major types of post-bum contracture involving the volar and dorsal side of the hand: flexion contracture of the MP joint, flexion contracture of the PIP joint, adduction contracture of the thumb, and extension dorsal contracture. A surgical scar excision may also be necessary for oncologic reasons: a squamous carcinoma may arise on a bum scar. Debridement of scar tissue and correction of joint (4) contracture must be followed by flap coverage: in our experience the use of a skin graft to replace the scarred skin has often caused recurrence of the contracture and failure of the surgical treatment.
Various types of flap can be used to resurface the hand after debridement: in our series we have more often used an island radial sensitive flap or an abdominal or brachial flap. We report a few cases to illustrate our technique and surgical refinements.

Case report 1

A 30-year-old woman sustained a bum of the left hand Aich caused severe flexion scar contractures of the MP and PIP joint of the third and fourth finger (Fig. 1).

Fig. 1 a) Pre-operative view: impressive flexion contracture of 3rd and 4th finger Fig. 1 a) Pre-operative view: impressive flexion contracture of 3rd and 4th finger
Fig. 1 b) Intra-operative view Fig. 1 b) Intra-operative view
Fig. 1 c) Final result at 1 year Fig. 1 c) Final result at 1 year

Her thumb was also involved by the bum and a hypertrophic scar was present.
First we performed a complete debridement of the scar tissue and correction of the NIP and PIP flexion by the use of Kirschner wires. The coverage of the volar defect was obtained with a cross-arm flap. The patient refused correction of the thumb scar.
Three weeks later we completed the reconstruction: the patient began rehabilitation and at 10 months both functional and cosmetic results were satisfactory.

Case report 2

A 22-year-old man sustained bums of the face, arms, hands and lower extremities. All bum areas were resurfaced with split-thickness skin graft (Fig. 2).

Fig. 2 a) Pre-operative view: adduction contracture of the thumb Fig. 2 b) Final result after correction of the right hand with an abdominal flap
Fig. 2 a) Pre-operative view: adduction contracture of the thumb Fig. 2 b) Final result after correction of the right hand with an abdominal flap

A severe contracture of the first web of both hands was the result of the bum healing and scarring of grafted skin. The contracture imposed a surgical procedure initially at the level of the right hand. the first web was reconstructed by means of an abdominal flap. At 9 months the functional improvement was impressive and the cosmetic effect was also satisfactory.
The patient did not return for treatment of the left hand.

Case report 3

A 45-year-old man sustained a bum of the volar side of the hand. A contracture of the first web and chronic ulceration of the bum scar developed during the following months. Debridement of the scar tissue was performed; an island sensitive radial flap was carried out to reconstruct the first web and thenar region. 8 months after the operation the functional and morphological results were excellent, with recovery of sensitivity (Fig. 3).

Fig. 3 a) Pre-operative view: chronic ulceration of a burn scar with developing contracture of the first web Fig. 3 a) Pre-operative view: chronic ulceration of a burn scar with developing contracture of the first web
Fig. 3 b) Intra-operative view: the island radial flap Fig. 3 b) Intra-operative view: the island radial flap
Fig. 3 c)-d) Post-operative view 8 months later Fig. 3 c)-d) Post-operative view 8 months later
Fig. 3 c)-d) Post-operative view 8 months later

Discussion

Post-bum contractures of the hand require appropriate surgical treatment whenever conservative approaches have failed.
The purpose of every surgical operation is to carry out a stable coverage of the involved area and to avoid recurrence of contracture or chronic ulcers or breakdown. In our series satisfactory results have been obtained using forearm radial flaps or abdominal or brachial flaps transferred to the hand by means of cross-arm. flaps.
A radial forearm island flap can be used in a single intervention to release severe contractures of the first web, thenar region, and dorsal region using its complete rotation arc. We can also restore sensitivity to the Injured hand. The cross-arm flaps (abdominal or brachial) do not restore sensitivity and impose on the patient considerable immobilization; also, the use of skin grafts is not effective to improve the functional aspect and to ensure a stable result; the recurrence of contracture or chronic breakdown is often observed and a second surgical operation is necessary.
Therefore the use of a flap is the only surgical procedure that ofrers functionally and cosmetically satisfactory results.

RÉSUMÉ. Quand les appareils statiques et dynamiques ne sont pas suffisants pour améliorer le résultat fonctionnel et esthétique des contractures à la suite des brûlures, il faut souvent recourir au chirurgien. La technique du lambeau est la seule procédure chirurgicale qui offre des résultats positifs. Les Auteurs présentent trois cas.

BIBLIOGRAPHY

  1. Tajima E: Treatment of post-traumatic contracture of the hand. J. Hand Surg., 13: 118-129, 1988.
  2. lbaraki K., Tajima T., Watanabe Y., Seki T.: Analysis of the effect of corrective splinting and operative release in the post traumatic contracture of finger joints.
  3. Kraemer M.: Burns contractures: incidence, predisposing factors and results of surgical therapy. J. Bum Care, 9: 261-265, 1983.
  4. Cannon B., May LW: Skin contractures of the hand. In: J.E. Flynn (ed.), "Hand Surgery", 3rd ed., Williams and Wilkins, Baltimore, 776-785, 1982.

 

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