Analysis of upper limb contractures: a 5-year study of 786 patients.
A burn patient who receives the best of treatment is expected to heal without any contracture.  The incidence of post burn contracture is extremely high in our country. Quite often, they are not only multiple in a given patient but also very severe and diffuse. The number of trained burn and plastic surgeons is less as compared to burns patients. The patients are treated by a variety of service providers who aim in closing the raw wound and this leads to invariably development of wound contraction and scarring.
An understanding of the burn wound healing is fundamental not only to the management of the acute burn wound, but also for the prevention, minimization and treatment of post-burn scars and scar contractures.   Contraction is an active biological process by which an area of skin loss in an open wound is decreased due to concentric reduction in the size of the wound.
The reduction in size of wound causes lesser degree of connective tissue deposition and the amount of epithelialization needed is decreased. Wound contraction involves an interaction of fibroblasts, myofibroblasts and collagen deposition and is a satisfactory mechanism when the tissue loss is small in a non-critical area and surrounded by loose skin. Scar contracture, on the other hand, is the end result of the process of contraction. 
MATERIAL & METHODS: A Performa was designed to record the data of patients seeking treatment for upper limb post burn contractures in OPD and Plastic Surgery ward in the Department of Plastic Surgery, Gandhi Medical College and associated Hamidia Hospital Bhopal (MP). The study population consisted of 786 patients from January 2011 to September 2015, who were seen and admitted to our hospital for operation. The parameters analysed were age, sex, time of burn, type of burn, site of contractures and operative procedure.
RESULT: The material consists of the 786 patients we treated for a upper limb contracture in the 5-yr period, 2011-15.
This case report shows more of females preponderance as compared to males, mainly due to more exposure of females to household works/kitchen works and less care of post burn leading to burn contractures.
Above table shows peak age distribution between 11-40 years, mainly due to early exposure to thermal burns, as females in our part of the world indulge in household activities early during their routine work.
Above table shows thermal burns as the most common cause of burn mainly due to use of chimny, sighris, stove and kerosene chulhas for kitchen attributes and also that females are more predisposed to burns as shown above.
Thermal 543 Electric 189 Chemical 37 Scald 17 Note: Table made from pie chart. No of Cases Accidental 561 Suicidal 172 Homicidal 53 Note: Table made from pie chart.
Above table concludes that elbow is the most common site of post burn contracture followed by finger contractures probably may be due to poor wound care and inadequate physiotherapy.
Above table shows the techniques used for post burn contracture release with effective outcome was split thickness grafting (STG) as a reconstructive surgical technique.
DISCUSSION: Upper limb contracture after deep burns is still a common complication seen in OPD in spite of better treatment now available, early initiation of physiotherapy and the early surgical treatment of deep burns. We operate approximately 156 upper limb contractures per year. The most important and effective method of controlling the wound contraction is to close the wound at the earliest using split skin graft in deep dermal and full thickness burns. Contraction can be inhibited by applying grafts to fresh wounds (As in early excision) or over healthy granulating areas (After eschar separation).
Although full thickness skin grafts inhibits contraction almost completely, but it is not possible in all cases. The split skin graft may also need expansion with meshing in extensive burns. Although this leads to complete healing of wound, with epithelium in interstices of the meshed graft. It is widely believed that thicker the graft, greater will be inhibition of the contraction. This holds true only if the grafts are harvested uniformly. It is the total percentage of dermal thickness grafted, which determines how much contraction will be inhibited. Delayed application of skin graft does not inhibit contraction effectively as immediate grafting. 
The scar collagen and elastin are relatively uncrosslinked and malleable during their initial deposition. Gentle, passive and sustained stretching exploits this malleability and is an effective technique for the lengthening of bands of scar tissue and increasing range of motion in early stages of developing contractures. Surgical intervention after preoperative planning and the necessary lab examination, the operation was performed under general anaesthesia or regional anaesthesia.
Complete release of contracture was done, avoiding damage to any important underlying structure, e.g., arteries, nerves, tendons while excisting extra fibrous tissue. As we know contracture occurs in all directions, but the incision begins across the point of maximum tension, i.e., where the contracture is most tight. The incision was zigzag deepening through the contracting scar, saving as much as unscarred healed burned tissues, which is not required to be replaced by skin graft.  The incision is deepened all the way to down till the vascular bed is reached.
All the scarred tissues responsible for the contracture was removed. Full release of the contracture was achieved by means of peripheral incisions and multiple darts at appropriate points along the periphery of the defect respecting anatomical creases across the joints. After the complete release of a post burn contracture, the recreated defect was covered using skin graft or a skin flap.
Most commonly, the raw areas resulting after release of post burn contracture were covered with skin graft. Flap covers were used only when required to cover bare tendons, nerves, vessels, bone or joints only. Elevation of the limb was maintained in postoperative period in order to prevent oedema. We used antibiotics in perioperative period only.
Skin Graft: Split skin graft of intermediate thickness or full thickness skin graft were used. Sheet graft were preferred. The junction line of the sheets of the graft were parallel to the axis of joint motion. Skin graft are immobilised by one or more of the various technique, viz., tie over dressing, plaster of paris splint, crepe bandage, elastoplast, etc., depending upon the site. The grafts were initially assessed on the fourth or fifth day after the operation. Thereafter, dressing changes were carried out every two or three days.   
Skin Flap: There are a few situations where a skin flap is a must. If the contracture release is likely to open up the joint or tendon/nerve as mostly seen in post-electrical burn contractures. Local flap in the form of Z plasty, VY plasty and transposition flaps were used. Flaps decrease the need for postoperative splintage to prevent secondary graft contraction.   Maintenance of released/corrected position is mandatory until the graft has become stable or till the flap margins have healed.
Postoperative use of static or dynamic splints, interspersed with a routine of daily physical therapeutic exercise is required to keep the joints in full range of motion. This therapy is continued till the graft is matured and complete range of motion is achieved. All grafts were lubricated with coconut oil in postoperative period to prevent cracks due to stretching while doing mobilization across the joint during physiotherapy.
CONCLUSION: There is increasing tendency of hypertrophic scarring and contracture seen in second degree deep burns when it has taken more than 3 weeks to heal. It has been noticed that early coverage of wound decreases contracture formation. Splinting from day 1 of burns is very important for prevention of contractures and it also improves results in post-operative cases. Application of split thickness skin graft after release of contracture even with strict splinting & meticulous follow-up has still yielded recurrences. Post-operative splinting and physiotherapy can reduce the recurrence and improved compliance of patient can finally make results better with functional rehabilitation as well.
With this study we can conclude that:
1. Post burn contractures being more common in uneducated society with limited patient follow-up and poor health awareness. These contractures can be prevented during in-patient care of burn victims.
2. Upper limb contractures are better prevented than treated. This means careful treatment of the burned limb, especially in deep second- or third-degree burns. Early surgical treatment of deep wounds, immobilization, and application of early escharectomy with immediate skin grafting should be preferred and is advocated.
3. If already established, a post-burn limb contracture must be treated as soon as possible. This will yield better results. Early treatment of established contractures prevents tissue fibrosis, tendon shortening, and joint stiffness.
4. Careful planning and timing of the different stages of treating a contracted burned limb are very important for better final results.
5. At the time of discharge proper education of postoperative care & adequate information of oil massage, physiotherapy and pressure garment should be given to the patient and their relatives.
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Arun Bhatnagar (1), Anand Narayan Gautam (2), Pranay Choubey (3)
(1) Professor & HOD MCh, Department of Plastic Surgery, Gandhi Medical College Associated Hamidia Hospital, Bhopal.
(2) Assistant Professor MCh, Department of Plastic Surgery, Gandhi Medical College Associated Hamidia Hospital, Bhopal.
(3) Resident, Department of General Surgery, Gandhi Medical College Associated Hamidia Hospital, Bhopal.
Financial or Other, Competing Interest: None.
Submission 05-11-2015, Peer Review 06-11-2015, Acceptance 09-11-2015, Published 17-11-2015.
Corresponding Author: Dr. Anand Narayan Gautam, Sr, MIG 61, Sahyadri Enclave, Opposite Wireless Office, Bhadbhada Road, Bhopal-462003, Madhya Pradesh.
Table 1: Sex Distribution Year Male Female Total 2011 93 99 192 2012 77 88 165 2013 70 82 152 2014 64 78 142 2015 58 77 135 Table 2: Age Distribution Age(in years) No of Cases Percentage 0-10 74 9.4% 11-20 196 24.9% 21-30 302 38.4% 31-40 137 17.5% 41-50 43 5.5% 51-60 25 3.2% >61 09 1.1% Table 3: Cause of Burn Type of burn No of Cases Percentage Thermal 543 69% Electric 189 24% Chemical 37 4.8% Scald 17 2.2% Table 4: Type of Burn Type of burn No of Cases Percentage Accidental 561 71.4% Suicidal 172 21.9% Homicidal 53 6.7% Table 5: Site of Contracture Site of contracture No of Cases Percentage Axilla 118 15% Axilla & Arm 32 4% Elbow 194 24.7% Dorsum of Hand 64 8.1% Wrist 83 10.6% Palm 57 7.2% Web space 93 11.9% Finger 145 18.5% Table 6: Surgical Technique Surgical Technique No of Cases Percentage FTG 59 7.5% FTG with Z-plasty 18 2.2% Z-plasty 53 6.8% STG 572 72.8% STG with Z-plasty 61 7.8% FLAPS 23 2.9%
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|Title Annotation:||Original Article|
|Author:||Bhatnagar, Arun; Gautam, Anand Narayan; Choubey, Pranay|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Nov 19, 2015|
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