Annals ofBurns and Fire Disasters - vol. IX - n. 3 - September 1996

BURNS SEQUELAE IN CENTRAL AFRICA: REPORT ON THE TREATMENT OF ELEVEN CASES

Gandini D.

Divisione di Chirurgia Plastica, Ospeclale di Cisanello, Pisa, Italy

SUMMARY. The results are presented of 11 cases of burn sequelae, mainly in children, treated by an Italian team in the Zambian-Italian Hospital in Lusaka (central Africa). From a technical point of view the surgical procedures do not present particular problems, but in the social context of central Africa they assume great value because they not only improve the quality of life of the unfortunate children but may become a sine qua non for their survival. In Zambia, as in all central Africa, burns are not treated in any specific way. The few surviving patients suffer from extremely severe scar contractures, with tragic consequences. This paper describes the cases treated and the results obtained.

Burns are frequent accidents in central African rural areas. The routine use of fire for domestic needs and the flammable materials used for the construction of huts are the main causes of burns. Zambia, like most other countries in central Africa, lacks a specialized burns unit. Fluid replacement therapies and infection prevention techniques are performed only occasionally and in very few hospitals. Even basic treatment is difficult to administer in many instances - most patients receive no therapy whatsover and the burns are left to heal spontaneously.
McCarthy' asserts that in primitive and archaic societies children with congenital deformities are "often removed from the tribe or cultural unit and left to die in the surrounding wilderness.
A similar attitude, although not so radical, can still be observed in central Africa with regard to any kind of congenital and acquired handicap. Possibly also the fatalism of the African way of thinking has a negative influence on this attitude. The quality of life for a handicapped child in central Africa is extremely poor, and a severe scar contraclure can easily become a tragedy. As a result mortality due to burns is very high, and even burns of medium severity can result in very severe scar contracture. The burned child is doomed to a tragic and desperate life without any social support except that offered by humanitarian and religious organizations, which cannot however cover the whole country.
Consequently, simple routine surgical procedures can not only improve the quality of life of these unfortunate children but sometimes become a sine qua non for their survival.
In summer 1995 1 had the privilege of serving as Junior Surgeon in an Interplast Team (Senior Surgeon, Paolo Santoni-Rugiu, M.D., Ph.D.) in Zambia. In the hospital where our team was working (Zambian-Italian Hospital for Handicapped Children, Lusaka; Chairman, Prof. J.G. Jellis, FRCS) a great number of patients who suffered burn injuries in the past were observed.
It may be of some interest to report on the rehabilitation of the cases of scar contracture that 1 had the opportunity to treat, since such cases are rarely observed nowadays in the western world.

Eleven patients with severe post-burn scar contractures were treated, of whom nine were aged between 6 and 10 years and the other two respectively 16 and 48 years.All the children in this series showed signs of nutritional deficiencies and lab tests showed constant severe anaemia (Hb less than 9).
Bum injury four years previously in right lower limb. Scar contracture with severe flexion of right knee (45'); foot also flexed and adherent to anterior aspect of the leg (Fig. 1).

Fig. 1 - Severe post-burn contracture of knee and ankle. Fig. 2 - Scar incised on anterior aspect of ankle. Tendolysis performed. Fig. 3 - Kirschner wire used to stabilize joint after tibiotarsal capsulotomy. Fig. 4 - De Bastiani external device used to maintain and gradually increase extension by daily adjustment of screw. Fig. 5 - De Bastiani external device used to maintain and gradually increase extension by daily adjustment of screw. Fig. 6 - Complete extension obtained within 35 days. External fixation device removed. Patient initiates physiotherapy after 10 days.

The patient was operated on in general anaesthesia. The scar in the knee was relaxed with a Z-plasty. The extension was obtained through elongation of all the flexor tendons, which was obtained by dividing them along the axis, and capsulotomy of the knee. The flaps of the Z-plasty were insufficient to cover all the raw area in the posterior aspect of the limb and two skin defects in the thigh and leg had to be covered with a split skin graft.
The foot was mobilized by incising the scar anteriorly (Fig. 2). The tendon of the long peroneal muscle was elongated by dividing it along the axis while the tendon of the peroneal brevis was simply cut. A tibiotarsal capsulotomy completed the extension of the foot.
The extension of the tibiotarsal joint was maintained with a Kirschner wire through the calcaneum (Fig. 3). External fixation with a De Bastiani device was applied on the femur and tibia (Fig. 4), thus allowing gradual and further extension for the following 25 days, until complete extension (Fig. 5). The external fixation was then removed (Fig. 6). The patient started physiotherapy 45 days after surgery.

2. Goodwin N., 7 yr. male
Whole hand involved in scarring process due to burn suffered some four years before. Severe flexion of hand on forearm (85') with subtotal fusion of palm with anterior aspect of wrist. Hyperextension of 2nd, 3rd, 4th and 5th fingers at metacarpophalangeal joints. Hyperflexion of interphalangeal joints.
The wrist scar was excised in general anaesthesia. During this manoeuvre neurolysis of the median nerve was performed. Particular attention was paid to the nerve, which did not seem to suffer as a result of the rapid extension. Capsulotomy of the wrist joint and tendolysis of all the flexor tendons were carried out. The entire ulnar group of muscles was detached from the epitrochlear and diaphyseal insertions in the ultia, thus allowing normal extension of the palm and fingers.
On termination of the operation extension was not complete - flexion was still about 25'. A De Bastiani external fixation was applied, which allowed gradual and progressive extension in the following weeks.
The external fixation was removed after 30 days, and physiotherapy commenced five weeks after surgery.

3. Raphael K., 6 yr, male
Burn on dorsum of left foot and distal aspect of leg three years before.
The burn healed spontaneously with no grafting of any sort. The boy presented a 65' flexion of the foot on the leg. The 5th toe was also hypetflexed. A vertical scar, 2 cm wide and 15 em long, was present on the posterior aspect of the knee.
The scar in the popliteal area was excised in general anaesthesia and the defect closed with multiple Z-plasties.
The same procedure, with a simple Z-plasty, was used on the anterior aspect of the ankle, while the 5th toe was extended with a V-Y procedure and tendolysis of the extensor tendons.
A splint was applied. The patient was mobilized after 15 days, commencing physiotherapy and free motion of the extremity.

4. Sueba Z ' 7 yr, female
Burn in lower third of face and upper third of neck two years before. Right arm and shoulder also burned. Healing achieved without medical treatment, leaving retracting scars.
The patient presented thick, retracting keloid scars in the mental and submental regions, and hypertrophic scars in the anterior cushion of the the right axilla and the anterior aspect of the elbow.
The keloids in the face and neck area were removed in general anaesthesia and the defect closed with a full-thickness skin graft from the groin. Retractions in the axilla and elbow were corrected with excision of scars and Z-plasties.
There was no immobilization and the patient was discharged after seven days, with an invitation to exercise the right arm.

5. Chiesu M., 8 yr, male
Large scar occupying whole dorsum of left foot with median band about 1.5 cm wide retracting foot in 65' flexion.
A subtotal excision of the scar was performed in general anaesthesia, leaving the skin on the metatarsal joints and displacing it from the dorsum with a V-Y procedure. The rest of the defect was covered with a full-thickness skin graft from the groin. The patient was allowed to walk after two weeks.

6. Edson P, 6 yr, male
Limited but massive scar retraction of 3rd, 4th and 5th finger of right hand, with complete flexion of metacarpal and interphalangeal joints.
In general anaesthesia the scar was excised, tendolysis of the flexor tendons was effected, and the defect was closed with a full-thickness skin graft from the groin.
The position of the fingers was maintained with a splint, which was removed after two weeks allowing free movement of the fingers.

7. Majula G, 48 yr, female
Lady presenting several linear scars on face involving nasolabial folds and cheeks.
In local anaesthesia all the scars were excised at the level of the nasolabial folds and Z-plasties were performed, positioning the scar line as far as possible on the line of the fold.Excellent cosmetic results were obtained.

8. Mpande S., 6 yr male
Boy with severe scar retraction in right ankle (45') and knee (120') due to local burn two years previously.
In general anaesthesia the scar was excised and tendolysis was performed. The defects were covered with a skin graft from the groin.
The knee retraction was corrected by excision of the scar and Z-plasty.

9. Cristabel G 16 yr. female
This girl had suffered a severe burn of the left breast, shoulder, arm, forearm amd hand five years previously. She presented a distortion of the left breast, which was smaller than the right breast and entirely covered by scars. There was a moderate scar retraction in the anterior cushion of the axilla. The anterior aspect of the elbow was retracted by a linear scar (140'). The left hand was flexed on the forearm (50') with subtotal adhesion of the palm to the wrist; the 3rd, 4th and 5th fingers wore flexed tightly on the palm (Fig. 7).
In general anaesthesia, the scar at the wrist was incised, exposing the flexor tendons. Tendolysis was performed and elongation was obtained by dividing the superficial tendons distally to the metacarpal joints and the deep tendons proximally to the carpal tunnel, suturing the distal stumps of the superficial tendons with the proximal stumps of the deep tendons (Fig. 8). 'lie position was maintained with an external fixation device and the skin defect at the wrist and palm was grafted with a full-thickness skin graft from the groins (Fig. 9).
No procedures were performed at this time in the other scar contractures on the hand and the rest of the upper limb.
The graft took uneventfully and the hand was mobilized after five weeks, when physiotherapy commenced.

10. Mwanyaly K, 6 yr male
Fifth finger completely flexed because of a linear scar due to a local burn three years previously.
In general anaesthesia the scar was excised and a multiple Z-plasty was performed. Immobilization on a Zimmer splint was removed after seven days, leaving the finger free.

11. Enock G, 10 yr, male
Extremely severe scar retraction due to burn four years previously. Healing achieved without medical treatment (Fig. 10).
The anterior aspect of the neck was totally involved in the scar contraction, which also extended in the lateral aspects. The lower lip was displaced by the retraction down to the central portion of the sternal area (Fig. 11). The jaw was dislocated downwards and the boy had severe feeding difficulties.

Fig. 7 - Extreme contracture of right hand in girl aged 16 yr following hum suffered in childhood. Fig. 8 - Flexor tendons elongated by dividing superficial tendons distally at level of metacarpal joints and deep tendons proximally to carpal tunnel. Fig. 9 - De Bastiani device applied to maintain and increase extension by daily adjustment of screw. Raw area on wrist covered with full-thickness skin graft from groins.

The right anterior cushion of the axilla was severely retracted and the arm flexed on the trunk with no abduction. During the surgical operation tracheal intubation proved impossible. Intubation via the nose was repeatedly but unsuccessfully attempted as the trachea was grossly displaced towards the right side of the neck. The only possible anaesthesia was neuroleptoanalgesia and heavy sedation.
The neck scar was resected, exposing the various elements of the neck. The large defect was covered by means of a myocutaneous flap of latissimus dorsi, with an island of skin measuring 25 x 12 em which subcutaneously reached the lower portion of the neck and the upper part of the thorax defect. The submental and upper parts of the neck defect were covered with a split skin graft from the right thigh (Fig. 12).
The repositioned lower lip developed considerable oedema which took about a month to resolve. The boy was able to take any kind of food a few days after surgery. A partial portion of free skin graft did not take and the patient had a second operation three weeks later. This time healing was uneventful (Fig. 13).

Discussion

Peacock and Cohen have written: "wound healing abnormalities are among the greatest causes of human disability, deformity and even death.
Most of the above cases involved unusual post-burn scar contractures. It is well known that the process of wound healing, with the production of a normal scar, is the result of various biological processes which, in order to produce the best possible scar, must fulfil a number of requirements, without which it is difficult to obtain normal epithelialization, collagen metabolism, and contraction with a soft but stable scar.
Peacock and Cohen' studied this process extensively. They found that post-trauma nutritional deprivation and certain types of immunosuppression impair the quality of scar production. In particular, the role of vitamin A in determining normal contraction was stressed by Herlich grafts and Hunt' and by Herlich, Tarver and Hunt.' Ascorbic acid deficiencies and hypoxia also appear to play a role in the production of normal collagen molecules, as demonstrated by Stein and Keiser' and Cohen and Keiser'.

Fig. 10 - Result of spontaneous healing of burn injury suffered four years previously by boy aged 10 yr involving neck, right shoulder and right arm. Fig. 11 - Displacement of lower lip down to thorax and of mandible showing malocclusion of about 2 cm. Right shoulder also contracted medially and abduction prevented by sear. Fig. 12 - Skin defect following resection of scar on neck and subelavicutar region closed by latissimus dorsi flap with island of skin measuring 25 x 12 em and with split skin Fig. 13 - After two weeks lower lip still very oedematous. Neck mobile. Right shoulder hypotrophic. Patient initiated physiotherapy 45 days after surgery after return of Interplast Team to Italy.

Frank, Brahme and Van der Berg' studied the influence of splinting and pressure on the regulation of scar contraction.
These and other factors may have interfered with the process of normal scar production in the patients described in this series. The fact that nutritional deprivation, hypovitaminosis, anaemia and therefore hypoxia are almost endemic among rural populations in central Africa most probably accounts for the unusual severity of the contractures.

RESUME. U Auteur présente les résultats de 11 cas de séquelles de brûlures, principalement dans des enfants, traitées par une équipe italienne dans l'Hôpital Zambien-Italien à Lusaka (Afrique centrale). Du point de vue technique les procédures chirurgicales ne présentent pas de problèmes particuliers, mais dans le contexte social de l'Afrique centrale elles améliorent la qualité de vie de ces enfants malheureux et bien souvent constituent la condition sine qua non pour leur survie. En Zambie, comme toute l'Afrique centrale, les brûlures ne sont pas traitées en manière particulière. Les rares patients qui survivent sont atteints de contractures des cicatrices extrêmement sévères, avec des conséquences tragiques. L'Auteur décrit les cas traités et les résultats obtenus.

BIBLIOGRAPHY

1. McCarthy J.: "Plastic surgery", 4: 2437. W.B. Saunders Co.,Philadelphia, 1990.
2. Peacock E.E., Cohen J.K.: Wound healing. In: McCarthy J., "Plastic surgery", 1: 161. W.B. Saunders Co., Philadelphia, 1990.
3. Herlich H.P., Hunt T.K.: The effects of cortisone and anabolic steroids on the tensile strength of healing wounds. Ann. Surg., 170: 203, 1969.
4. Herlich H.P., Tarver H., Hunt T.K.: Effects of vitamin A and glucocorticoids upon inflammation and collagen synthesis. Ann. Surg., 177:222,1973.
5. Stein H.D., Keiser H.R.: Collagen metabolism in granulating wounds. J. Surg. Res., 11: 277, 1971.
6. Cohen J.K., Keiser H.R.: Disruption of healed scars in scurvy. The result of a disequilibrium in collagen metabolism. Plast. Reconstr. Surg., 57: 213, 1976.

7. Frank D.H., Brahme J., Van der Berg J.S.: Decrease in rate of wound contraction with the temporary skin substitute Biobrane. Ann. Plast. Surg., 12: 519, 1984.

Acknowledgement
The author wishes to thank Prof. P. Santoni-Rugiu, Senior Surgeon of the Interplast Team in Zambia, for giving him responsibility for the treatment of the patients in the series described in this article and for his suggestions and constructive criticisms as the article was conceived and written.