Ann. Medit. Burns Club - vol. V111 - n. 2 - June 1995

THE RHOMBOID RELEASE: A NEW APPROACH TO THE MANAGEMENT OF DIGITAL BURN CONTRACTURES

Uzunismail k Kahveci R, Ozdemir A, Bozdogan N ., Yuksel F.

SUMMARY. A new approach, the "rhomboid" release, was used for chronic moderate flexion contractures of the fingers due to burns in nine adult cases. All patients progressed well post-operatively. The follow-up period was six months to one year without long-term problems. As an alternative to other reconstruction methods, the procedure was found to be versatile especially in the treatment of long-standing bum contractures limited to the palmar skin and causing extension deficits of less than 80'. The result of the procedure in one illustrative case is presented together with a review of the related literature.

Flexion contractures of the fingers due to deep burns can present challenging problems. They may be limited to the volar skin or involve deeper structures, causing severe deformity with limitation of finger movements. Various methods have been proposed for the management of chronic flexion contractures of the digits. These range from simple release of the contractures with graft coverage to a number of flap procedures, including Z-plasty. When we are dealing with contracture release, reconstruction of the secondary defects by surface covering should be evaluated first. Unless adequate coverage is provided, many of the secondary wound healing problems can cause residual joint contractures (1). Pre-operative tissue softening by means of passive stretching of the contracture can sometimes be utilized as an aid to surgical treatment.

Under brachial block with tourniquet, a 60-120' rhom~ boid incision is planned on the most prominent part of the contracture while the finger is as far extended as possible. Incision begins from the proximal and distal edges of the rhomboid, with the finger maintained in the extended position. The incision is then continued to the radial and ulnar edges. When the incision is complete, the contraction is released perpendicularly by using both faces of the blade. It is very important to avoid horizontal undermining in order to preserve the blood supply to the rhomboid skin island. After release of the contracture at the proximal and distal edges, the palmar skin adjacent to the ulnar and radial edges of the rhomboid are incised 2-3 man vertically to facilitate further release if necessary. Care is taken not to injure the neurovascular bundle which can easily be identified under microscopic magnification.
The tourniquet is released and the rhomboid skin island is checked for its viability. The secondary and proximal and distal palmar defects are then closed in V-Y fashion. The u1nar and radial tongues of the rhomboid are advanced into the V-shaped defects which are secondary to the vertical incisions on both sides, if used (Fig. ]a, b, c).

We used rhomboid release in 15 fingers of eight male and one female patients (aged 20-22 years), with moderate flexion deformities and extension deficits varying from 40 to 80' due to burns (Table 1). We demonstrate one example that has been documented photographically.

A 22-year-old serviceman (case 5) had chronic flexion contractures, causing 50' and 60' extension deficits of the left index and middle fingers respectively, due to flame burns sustained in childhood (Fig. 2). The deformity followed conservative treatment which led to difficulty in using the hand, and he clearly required medical treatment. He had not undergone any previous surgery. After the contractures over the PIP joints had been released by rhomboid incisions (Fig. 3), the secondary defects were closed in V-Y fashion. The fingers regained full extension. The patient progressed well post-operatively and presented no problems in the one-year follow-up period (Fig. 4).

Although volar contractures of the fingers are less fre quently seen than dorsal contractures, they may nonethe less constitute major problems. Many palm burns that heal spontaneously may continue to develop significant scarring and eventually contractures. Chronic moderate flexion contractures of the fingers must be regarded not only as cosmetic but also as functional problems. Such deformities may be limited to surface problems of palmar skin or be caused by underlying deep structures, such as vessels, nerves, tendons, joints or bones. If the deformity involves the dominant hand, the patient may have addition al problems.
A number of methods have been developed for the treatment of digital burn contractures of various degrees. The simplest of these would appear to be release of the contracture by perpendicular incisions and coverage of the secondary defect by skin graft.' This method is not however free of problems. The releasing incisions should reach as far as unscarred tissue so that the us~fulness of residual palmar skin is maximized. Some controversy exists concerning the use of split- or full-thickness graft after release of contractures. Pensler et al.' advocate splitthickness graft while Jackson' prefers full-thickness graft as this is believed to be more durable and to result in fewer recurrent contractures. Alexander et al.' have suggested that there is no major functional difference in the use of split- or full-thickness graft. After complete contracture release, flap coverage seems to be the most desirable method of treatment, especially in cases where deep structures such as tendons or joint capsules are exposed.' Pre-operative passive stretching may be useful in all release procedures as an aid to surgical treatment.'

Fig. 2 - Pre-operative appearance of long-standing digital contractures in index and middle fingers of left hand and drawings of incisions. Fig. 3 - Intra-operative appearance of the procedure.

In chronic cases with exposure of tendons or joint capsules, the following procedures have been used: crossfinger flap,' Z-plasty with or without accompanying skin grafts, V-shaped flap' and double opposing V-Y flap.` In our department, multiple Z-plasty, side finger flap and five-flap Z-plasty have all been used routinely in selected cases, in addition to the combined use of side finger flap and cross~finger flap in severe cases.`

Ex~ept for the double opposing V-Y flap procedure, all the reconstruction procedures related to flap use have necessitated additional grafting either for secondary defects or for coverage of flap donor areas.
We have found that rhomboid release, as named by us, is versatile and provides 5-8 mm of tissue gain in both the distal and the proximal edges of the contracture, making a total gain of 1-1.6 em. In the management of cases with moderate digital contractures with extension deficits of less than 80' and with only limited volar skin, the method has provided solid coverage without necessitating additional graft. In two cases with extension deficit of 80', only a 10-20' deficit remained (Table I). This method has also been found to be advantageous compared to other flap construction methods, especially those requiring additional grafting in terms of innervation, skin texture, durability and cosmetic appearance. It can be practised on more than one finger in the same operating session.
We conclude that this new method can be added to the plastic surgeon's armamentarium as a reliable and simple way of releasing long-standing contractures of the fingers.

RESUME. Les auteurs ont utilisé une nouvelle méthode, le "dégagement rhomboïdal", pour les contractures chroniques modérées de flexion des doigts causées par les brûlures dans neuf cas adultes. Tous les patients ont fait de bons progrès post-opératoires. La période de suivi post-hospitalier de six mois jusqu'à un an n'a pas présenté de problèmes à long terme. Comme alternative à d'autres méthodes de reconstruction, cette procédure s'est montrée très utile, particulièrement dans le traitement des contractures de longue date dues aux brûlures limitées à la peau palmaire et qui causent des déficits d'extension de moins de 80'. Les auteurs présentent les résultats de la procédure dans un cas qui sert à illustrer le problème et ils passent en revue la littérature relative.

BIBLIOGRAPHY

1. Doneland M.B.: Reconstruction of the burned hand and upper ex-trenrity. In: McCarty J.G., May J.W., Littler J.W. (Eds): "Plastic Surgery", p. 5452, W.B. Saunders Co., Philadelphia, 1990.
2. EI-0tefy M.A.: A versatile method for the release of bum scar contractures. Brit. J. Plast. Surg., 34: 326, 1981.
3. Pensler J.M., Stew4rd R., Lewis S.R., Hemdon D.N.: Reconstruction of the burned palm: full-thickness versus split-thickness skin grafts long-term follow-up. Plast. Reconstr. Surg., 81: 46, 1988.
4. Jackson I.T.: Discussion. Plast. Reconsfir. Surg., 68: 225, 198 1. it.
5. Alexander J.W., MacMillan B.G., Martel C., Krummel R.: Surgical correction ol'postburn flexion contractures of the fingers in children. Plast. Reconstr. Surg., 68: 218, 198 1.
6. Matthews R.N., Morgan B.D.G.: Multiple seagull flaps for digital contractures in electric burns. Brit. J. Plast. Surg., 40: 47, 1987.
7. Joshi B.B.: Percutancous internal fixation of fractures of the proximal phalanges. Hand, 8: 86, 1976.
8. Jackson I.: A method of treating chronic flexion contractures of the fingers. Brit. J. Plast. Surg., 23: 373, 1970.
9. Gibraiel E.A.: A local finger flap to treat post-traumatic flexion con tractures of the fingers. Brit. J. Plast. Surg., 30: 134, 1977.
10. Nathan P.A.: Double V-Y flap for correction of proximal interphalangeal joint flexion contractures. J. Hand Surg., 9A: 48, 1984.

11. Numanoglu, A., Bas L., Celebiler 0.: Reconstruction of severe flexion contractures of the fingers by the neurovascular laterodigital flap combined with crossfinger flap. Program and Abstracts Book, p. 226. Presented at IPRS, Fifth Congress of Asian Pacific Section, Istanbul, Turkey, September 1989.