Classifications of Post Burn Axillary Contracture: Reappraisal of its Rationale HAMDY BASHA,
M.D. and MOHAMED HAMDY ABDULLA, F.R.C.S. ABSTRACT Since 1991, 20 cases of postburn axillary contracture have been classified and managed according to the basis of functional disability; mainly limited abduction. The distance from the tip of the middle finger to the axillary pit+the distance from the axillary pit to the anterior superior iliac spine when all the joints limb are full extended and the shoulder is full abducted point out to 0 amount of soft tissues deficiency. In axillary contracture the distance between the tip of the middle finger and the anterior superior iliae spine will be less than the above distance. The. difference between the two will correspond to the amount of soft tissue deficiency. The versatility and validity of the island latissimus dorsi myocutaneous flap have also been discussed. Marked improvement in all shoulder joint movements were achieved. INTRODUCTION Postburn axillary contractures almost always interfere with and limit the shoulder joint movements; mainly the abduction. Classifications of postburn axillary contracture were based on either the scar morphology or its extent. Both of these classifications do not entail about the amount of tissues loss and the relation between the scar shape and extent with the limitation already presented. Leung, [8] reported 3 types of postburn axillary contracture as follows:
Toet and Bosse [4] classified postburn axillary contractures after Yang et al. (1982) into three types depending on the extent of the scaring as follows:
They also provided the latissimus dorsi myocutaneous flap and the scapular flap respectively as the procedures of choice in the management of the severe type. As postburn axillary contractures are mainly due to soft tissue deficiency from thermal or chemical injuries, the shape of the scar is not relevant to the degree of limitations and the relation between both is not clear if any. Sometimes the extent of scaring may implicate on the degree of limitations, but the thermal or cheniical injury is not unique in their features and outcome. It is not uncommon to find overlap between different types. This work suggests a functional classification depending on the degree of abduction limitation which is closely related to the amount of soft tissues deficiency. It has a value in preoperative planning and postoperative prognosis. MATERIAL AND METHODS During the last 8 years, twenty patients; 16 males and 4 females were studied, nineteen of them suffered unilateral postbum axillary contracture and only one had a bilateral axillary as well mentostemal contractures. Patient age ranged between 14:50 years, with the mean of 32 years. These patients developed axillary contracture inspite of early physiotherapy. The surface area of bum ranged between 15% - 50% and it was always deep second degree, sometimes complicated by infection. During preoperative preparation, X-ray to the shoulder joint revealed normal joint space. These patients were classified according to the functional disability as follows:
Fourteen patients had mild
unilateral type, 10 of them were treated by multiple z plastics and 4 by rectangular flap
to provide full abduction. Four patients suffered unilateral moderate contracture and the
rectangular flap aided by skin grafts to the residual defect was the treatment of choice.
The vertiele axis of the defect was always less than 15 cm. The abduction angle was less
than 90 degrees in two patients, one of them had bilateral contractures. The defect ranged
from 15: 22 em in the vertical axis. Both cases were managed by latissimus dorsi
myocutancous flap. The doner area was covered by split thickness skingraft.
The length of the limb from the tip of the middle finger to the axillary pit with full extension of all joints is given the letter A. The distance between the center of the axillary pit to the anterior superior iliac spine on the lateral chest wall is represented as letter B (Fig. 1A,B). In full abduction when the angle C 180 degrees: tissues loss = Zero and the distance C = A + B. But when the abduction angle is limited in axillary contracture, the C angle will become Cc (as small C for contracture) and the distance C will be less than A+B. So the amount of soft tissue loss will be = (A + B) - Cc (Fig. 1A,B). From the above equations and facts, the functional classification of the post bum axillary contracture is elaborated and it is easy to estimate the amount of soft tissues deficiency that helps better planning.
DISCUSSION Leung's classification [8] was based on morphological features of the scar and that reported by Toet and Bosse [7] after Yang 1982 was based on the extent of scarring. Both didn't entail or estimate the amount of tissue loss and the degree of limitation. These classifications cause confusion.Between different types of post bum axitlary contracture, as the scar shape or extent is not unique in its outcome as regards the limitation of movement. As the abduction of the shoulder joint has the largest range among the others, hence its selection as a base for grading the axillary contracture seems sound.The functional classification based on the degree of abduction prevent confusion in assessment and provides a clear idea about the deformity, the amount of tissue loss, the proper method for reconstruction and also it has a prognostic value.Also the measurements provided were of great value to plan the exact procedure instead of being planned after release the scar tissue while the patient is on the table. Although these measurements provide the vertiele diagonal of the defect, yet the horizontal diagonal should be considered while planning the flap.Toet and Bosse [7], described the lateral position which will help in full range of abduction after release the scar tissue. We also found that this lateral position provides direct access to the axilla and full range of abduction after release of the fibrous scarring.Leung et al. [8] used 8 pedicled latissimus dorsi myocutaneous flaps to reconstruct the severe postbum axillary contractue, with good results.Also Toet and Bosse [7], described the island scapular flap with maximum dimensions of 10x15 em to reconstruct the severe type according to their classification. We found that the island latissimus dorsi myocutaneous flap could provide 300 centimeter square or more to reconstruct the severe type according the the functional classification and quite suitable with any age and built. It also provides wide are of rotation and better distribution of the tissues.As it is a myocutaneous flap, the skin over it could be used even when scarred.Its versatility and validity have been reported in many reports to reconstruct various areas as the chest wall, upper arm and in post mastectomy reconstruction [1-6].Conclusion: We conclude that the suggested functional classification of post bum axillary contracture and the measurement provided by this report has the following advantages:
The true test of the value for the functional classification will be determined after the passage of time and evaluation by other surgeons. It is hoped that this classification as well as the measurement will be valuable to surgeons so that it can be safely and predictably applicable. REFERENCE |
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