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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 28  |  Issue : 4  |  Page : 852-857

Different surgical modalities for management of postburn flexion contracture of the elbow


1 Department of Plastic Surgery, Faculty of Medicine, Menoufia University, Egypt
2 Shebein el-kom teaching hospital, Egypt

Date of Submission13-Jan-2015
Date of Acceptance22-Mar-2015
Date of Web Publication12-Jan-2016

Correspondence Address:
Hisham Taha Ahmed
Elmahalla Elkobra, 317811, El Gharbia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.173603

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  Abstract 

Objective
A study evaluating the outcomes of different surgical modalities for management of the postburn elbow contracture.
Background
The incidence of the postburn contracture is unkown, but it is inversely propotional to the standards of the initial management.
Methods
This is a prospective study included 20 patients suffering from different degrees and forms of postburn elbow contracture. All patients had scar contracture release and then were managed according to the forms of the contractures and the availability of adjacent healthy unscarred tissues.
Results
Different techniques had been used in this study, seven cases had skin graft representing 35% of all cases, there was partial loss in one case and one case had recontracture later on. Five cases representing 25% of cases had z-plasty flap, only one case had tip necrosis. Two cases had five z-plasty technique representing 10% of cases and there was no complications including infection, dehiscence, hematoma, tip necrosis or recontracture. Three cases representing 15% of cases had reversed lateral arm flap and there was no complications. Three cases representing 15% of cases had proximally based lateral forearm flap and also there was no complications.
Conclusion
Flaps are better for resurfacing the defects after post-burn contractures release. Flaps do not need rigorous post-operative physiotherapy or splintage, no recurrence of contracture and grow with age especially in children.

Keywords: postburn contracture, the elbow joint, surgical modalities


How to cite this article:
Gad SS, Albarrah AM, Elkashty SM, Ahmed HT. Different surgical modalities for management of postburn flexion contracture of the elbow. Menoufia Med J 2015;28:852-7

How to cite this URL:
Gad SS, Albarrah AM, Elkashty SM, Ahmed HT. Different surgical modalities for management of postburn flexion contracture of the elbow. Menoufia Med J [serial online] 2015 [cited 2020 Feb 28];28:852-7. Available from: http://www.mmj.eg.net/text.asp?2015/28/4/852/173603


  Introduction Top


The mortality and morbidity from burns have diminished tremendously over the last six to seven decades. However, these do not truly reflect whether the victim could go back to society as a useful person or not and leads a normal life because of the inevitable postburn scars, contractures and other deformities which collectively have aesthetic and functional considerations. Postburn scars are inevitable even with the best of treatment because they depend upon the depth of burn injury. Except for the superficial dermal burns, all deeper burns (2nd degree deep dermal and full thickness) heal by scarring. Their actual incidence is unknown. However, the incidence is inversely proportional to the standards of initial treatment with patients receiving best of care having minimal number and severity of these problems than if left to heal conservatively [1] . Postburn scarring and contracture affecting function remain the most frustrating late complications of burn injury [2] .

They are characterized by tight, shortened scar tissue. They can form over joints, creating a limitation of movement or can create a deformity as the result of their effect on a mobile anatomic structure. They are more common on the flexor surfaces because these muscles are generally stronger and the flexed position is often the position of comfort [3] . Post burn scar contractures are classified into cutaneous/subcutaneous contracture. If tendon, ligament, and muscle contracture were diagnosed, these replacement and/or reconstruction methods should be considered in addition to releasing scar contractures [4] .

Elbow burn contractures are more likely to be complicated with heterotopic bone formation. The surgeon must be aware of this possibility, diagnose this before any skin contracture release, and plan operative strategy accordingly. Some surgeons perform both the skin release and heterotopic bone release in one sitting, although Ring reports the need for reoperation in 30% of patients. Baux et al., recommend two staged procedures [5] . Linear contracture can be managed with z-plasties, w-plasty, or small wave incision to release linear band in the midline (type Ia). In the case where the patient has linear scar contractures on both radial and ulnar surfaces, (type Ib). Broadband contracture on one surface are (type IIa), but broadband contractures on both radial and ulnar surface, are (type IIb). Broadband contractures extended to next surfaces are (type III). (type IV) is the contracture involving the entire circumference of the elbow [4] .

Before attempting release, the patient should be asked to wait preferably a year from the time of the burn, which can be frustrating to the patient. However, during this time massage, splinting and regular visits to the physiotherapist will pay dividends in the end [6] . One must allow the scar to become mature, soft, supple and less vascular before undertaking surgery for contractures [1] . Release of an elbow burn contracture usually produces a secondary defect that needs to be reconstructed with proper measures [7] .

Different techniques can be used to manage contracture of burn scars on the elbow, including skin graft, local, distant pedicle flaps, muscle or myocutaneous flaps, free flaps, and tissue expanders [8] . Incisional and excisional release and skin grafting were the mainstays of postburn reconstruction. However, using skin grafts in burn reconstruction has its own sets of problems. They are prone to contracture and recurrence that are common after contracture release and grafting. So, there is a prolonged need of splintage and physiotherapy in the postoperative period. Flaps are better for resurfacing the defects after release of postburn contractures.

Flaps do not need rigorous postoperative physiotherapy or splintage and grow with age especially in children. However, local unscarred tissue is not available most of the times [9] . Physiotherapy should be considered in the management of cases preoperatively and postoperatively, tailored to each case. Patients had to undergo a physiotherapy course under a specialist as a routine part of each technique. Patients were examined periodically for complications of healing (infection, ulceration, necrosis, wound dehiscence, hypertrophic scar, and contracture) [10] .


  Methods Top


This is a prospective randomized study included 20 patients aged from 4 to 52 years old. All of them were asking for elective release of postburn flexion contracture of the elbow at the outpatient clinics of Menoufia University and Shebeen El-Kom Teaching Hospitals. It was done from November 2013 to September 2014.

Different surgical modalities had been used in our study including: skin graft, z-plasty, five z- plasty, reversed lateral arm flap and proximally based lateral forearm flap techniques.

Written informed consents were obtained from all cases preoperatively.

Preoperative broad spectrum antibiotic was given IV 2 h before surgery.

The appropriate technique was selected for every patient putting into consideration the form of contracture and the state of surrounding tissue according to the clinical examination.

All cases were followed up in the outpatient clinics.

Follow up of the patients was continued not less than six months, monthly, regarding the viability of flaps and healing of the repaired area.

Physiotherapy was considered as an option in management of cases preoperatively and postoperatively according to each case.

Patients were examined periodically for complications of healing (infection, ulceration, necrosis, wound dehiscence, hypertrophic scar and contracture) and maximum degree of extension of the elbow joint gained.

Skin graft

This method was used in 7 patients representing 35% of the total patients. Careful release of the scar contracture was done along the axis of the elbow joint at the point of maximum tension with complete release with darting and fishtailing at the edges of the resulting defect, fenestrated intermediate thickness skin graft (STSG) was applied to the defect of the graft, postoperative splinting of the elbow was done ([Figure 1]).
Figure 1 Fishtailing of the scar contracture release incision.



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Z - Plasty

This technique was done in 5 patients representing 25% of all patients. It was done to release linear scar with good tissues along side ([Figure 2]). Under GA, with tourniquet control, the central limb of the z-plasty was incised over the scar to be lengthened, with the peripheral limbs of the z-plasty of the same length as the central limb with angles about 60°. The flaps were elevated and transposed to relieve the contractures.
Figure 2 Demonstrates linear band contracture along the midline of the elbow.



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Five z-plasty flap technique

This technique was done in 2 patients representing 10% of all patients. Preoperative marking was done while the patient's forearm was supinated to delineate the contracture and also to map the five flap technique to be used. Torniquet was applied, the design depends on balanced opposed Z-plasties along the line of contracture, with a middle Y-V plasty was advancing deep into the middle of the reconstruction ([Figure 3]). Finally, flaps elevation and transposition were done.
Figure 3 Demonstrates the design of the five z- plasty.



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The reversed lateral arm flap

This technique was performed in 3 patients, representing 15% of all patients. Doppler study was done to detect the vascular pedicle i.e. Posterior radial collateral artery (PRCA). The flap was marked as an ellipse, with its central axis upon a line drawn between the deltoid insertion and the lateral epicondyle, which corresponds to the lateral intermuscular septum, the patient was placed in a supine position with the arm lying across the chest and the elbow in flexion. Under tourniquet, careful complete release of the scar contracture was done. Flap elevation started at the posterior border in the subfascial plane, until the vascular pedicle was identified ([Figure 4]), then the anterior border was incised and the flap was dissected distally. Finally, the flap transposition was done to reconstruct the defect.
Figure 4 Identification of the vascular pedicle of the reversed lateral arm flap.



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Proximally based pedicled lateral forearm flap

This technique was done in 3 patients, representing 15% of all patients. Under GA, the patient was placed in the supine position. Release of the contracture was done first to estimate the defect size. Flap design was performed in a tongue-shaped fashion ([Figure 5]). Skin was incised then flap elevation and transposition to reconstruct the defect were done.
Figure 5 The design of the proximally based lateral forearm flap as tongue like .



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  Results Top


Skin graft technique

This had been used in 7 cases with variable degrees of postburn flexion contracture of the elbow, aged from 4 to 52 years old. All cases had full extension of the elbow on table,the take of the graft was complete in 6 cases, one case had partial loss and another case had recontracture, observed after 6 months during her follow up period. The donor site had no complications except one case had hypertrophic scar which was managed conservatively with pressure garments and silicon gel sheets.

Z-plasty

This had been used in 5 patients, with variable degrees of postburn elbow flexion contracture, aged from 16 to 42 years old. We used only the single Z-plasty for the release of all cases. All cases had full extension of the elbow on table. All cases healed with no complications as infection, hematoma, except for tip necrosis of one flap and it was treated conservatively. There was no recurrence of the contracture during the 6 months follow up period.

Five z-plasty technique

This had been used in 2 cases with variable degrees of postburn flexion contracture of the elbow, one case was 21 years old and the other was 33 years old. All cases had full extension (180°) of the elbow on table. The flaps were viable in all cases, with no dehiscence, hematoma, and infection, tip neither necrosis nor flap loss.

The reversed lateral arm flap

This had been used in 3 cases. With variable degrees of postburn flexion contracture of the elbow, aged from 4 to 20 years old. All cases had full extension of the elbow on table. All cases healed with no complications e.g. wound infection, dehiscence, hematoma, flap loss, distal necrosis or radial nerve injury, but the posterior cutaneous nerve of the arm and forearm were divided in all cases with subsequent sensory deficit in the form of numbness. The donor site was closed primarily in 2 patients when the width of the flap was 6 cm and STSG was applied only in one patient when the width of the flap was 8 cm. The donor site healed with no complications e.g. wound infection, dehiscence, hematoma, hypertrophic scar or keloid formation.

The proximally based lateral forearm flap

This had been used in 3 cases, with variable degrees of postburn flexion contracture of the elbow, aged from 4 to 21 years old. All cases had full extension of the elbow on table after the scar had been released. All cases healed with no complications e.g. wound infection, dehiscence, hematoma, flap loss or distal necrosis. The donor site was closed primarily only in one case while in 2 cases it was narrowed and grafted. The donor site healed with no complications e.g. wound infection, graft loss, hypertrophic scar or keloid formation.


  Discussion Top


Before attempting release, the patient should be asked to wait preferably a year from the time of the burn [6] . In our study we operated on the postburn scar after 6-12 months, after plateuing of the effect of the physiotherapy. One must allow the scar to become mature, soft, supple and less vascular [1] . Release of an elbow burn contracture usually produces a secondary defect that needs to be reconstructed with proper measures [7] . We have performed in our study the skin graft, Z-plsty, five z-plasty, the reversed lateral arm flap and the proximally based lateral forearm flap techniques. Skin grafting is an easy procedure, however, success is limited with the technique because there is always the risk of incomplete graft take and prolonged splinting and physiotherapy is imperative in the postoperative period. Despite the latter, grafting usually has a high possibility of recontracture [7] . This problem we had encountered after operating on 4 years old female child, during her 6 months follow up period as the graft doesn't grow with age, so it is better to be avoided in growing children.

Flaps are better for resurfacing the defects after release postburn contractures. Flaps do not need rigorous postoperative physiotherapy nor splintage and grow with age especially in children. However, local unscarred tissue is not available most of the times. Harvesting a tissue from the burnt area is possible, but there are increased chances of flap failure [9] . So, in our study, we avoided any axial flap elevation at the site of scarred tissues.

If a local skin flap in the form of Z-plasty for linear contractures, is available and will be sufficient in itself to treat the contracture, there is no reason why it should not be used. However, this flap is always has the risk of necrosis when raised in scar tissues [3] . In this study, we preferred the Z-plasty in linear band contracture, type Ia and Ib of negligible to mild cases and we had one flap tip necrosis.

The Hirshowitz's five z-plasty flap procedure is also very effective in the release of the linear scar band deformities. The triangular flaps of two opposite Z-plasties and a Y-V advancement flap constitute the five flaps [11] . For tight bands with unburned surrounding skin, Hirshowitz and Karey recommend a five z-plasty flap release [5] . We agree with this in our study for release and reconstruction of the linear band.

The favorable features of the reversed lateral arm flap are constant vascular pedicle, straightforward dissection; the donor site can be closed primarily if it is not wider than 6-7 cm and the no need for sacrifice a major artery or functional muscle [12] . Although the sensory deficit due to division of the posterior cutaneous nerves of the arm and forearm usually becomes unnoticeable by the patients and has been shown to get smaller by time, this area of numbness was reported to remain unchanged in 59% of the patients after long-term follow-up [13] . This problem, we had encountered in patients of our study with gradual improvement in sensory regain during the follow up period.

The pivot point of the proximally based lateral forearm flap is again the lateral epicondyle and the territory immediately proximal to it. Flap design may be best done in a tongue shaped fashion with possible primary closure of the donor site in most cases [14] . In our study, the donor site was closed primarily in two cases and in one case, we had used intermediate thickness meshed split thickness skin graft above and below the flap inset and for the donor site of the flap.


  Conclusion Top


Flaps are better for resurfacing the defects after postburn contracture release. Flaps do not need rigorous postoperative physiotherapy or splintage and grow with age especially in children. However, local unscarred tissue is not available most of the times. Harvesting a tissue from the burnt area is possible, but that will increase the risk of flap failure.

The use of local cutaneous and fasciocutaneous flaps is preferred, but requires the presence of local adjacent healthy unscarred tissues and healthy untraumatised donor sites in case of local fasciocutaneous flaps that may endanger the vascular pedicle of the flap. The local cutaneous flaps as the z-plasty and five z-plasty flap are preferred in case of linear band contracture with adjacent local healthy tissues, but there may be risk of tip necrosis. In case of broadband contracture with no local healthy unscarred tissues, then the use of skin graft will be necessary ([Table 1]).
Table 1 Illustrates the different techniques used according to the forms of contracture regarding to the improvement and any complication appeared later during the follow up period


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  Acknowledgements Top


None.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Goel A, Shrivastava P. Post-burn scars and scar contractures. Indian J Plast Surg 2010; 43 :63-71.  Back to cited text no. 1
    
2.
Iwuagwu FC, Wilson D, Bailie F. The use of skin grafts in postburn contracture release: a 10-year review. Plast Reconstr Surg 1999; 103 :1198-204.  Back to cited text no. 2
    
3.
Wainwright DJ. Burn reconstruction: the problems, the techniques, and the applications. Clin Plast Surg 2009; 36 :687-700.  Back to cited text no. 3
    
4.
Ogawa R, Pribaz JJ. Diagnosis, assessment, and classification of scar contractures. In: Hyakusoku H, Orgill DP, Teot L, Prribaz JJ, Ogawa R. Color atlas of burn reconstructive surgery. Springer; 2010. p. 44-60.  Back to cited text no. 4
    
5.
Schwarz RJ. Management of postburn contractures of the upper extremity. J Burn Care Res 2007; 28 :212-9.  Back to cited text no. 5
    
6.
Schwarz RJ, Joshi KD. Management of post-burn contractures. Journal of Nepal Medical Association 2004; 43 :211-216.  Back to cited text no. 6
    
7.
Aslan G, Tuncali D, Cigsar B, Barutcu AY, Terzioglu A. The propeller flap for postburn elbow contractures. Burns 2006; 32 :112-5.  Back to cited text no. 7
    
8.
El-Khatib HA, Mahboub TA, Ali TA. Use of an adipofascial flap based on the proximal perforators of the ulnar artery to correct contracture of elbow burn scars: an anatomic and clinical approach. Plast Reconstr Surg 2002; 109 :130-6.  Back to cited text no. 8
    
9.
Panse N, Sahasrabudhe P, Bhatt Y. Use of local perforator flaps for post burn reconstruction. World J Plast Surg 2012; 1 :22-9.  Back to cited text no. 9
    
10.
Walash A, Kishk T, Ghareeb FM. Treatment of postburn axillary contracture. Menoufia Med J 2014; 27 :278-83  Back to cited text no. 10
    
11.
Yang JY. In: McCauley RL, editor. Reconstruction of axillary contracture. Functional and aesthetic reconstruction of burned patients. New York: Taylor and Francis; 2005. 367-378.  Back to cited text no. 11
    
12.
Türegün M, Nisanci M, Duman H, Aksu M, Sengezer M. Versatility of the reverse lateral arm flap in the treatment of post-burn antecubital contractures. Burns 2005; 31 :212-6.  Back to cited text no. 12
    
13.
Graham B, Adkins P, Scheker LR. Complications and morbidity of the donor and recipient sites in 123 lateral arm flaps. J Hand Surg Br 1992; 17 :189-92.  Back to cited text no. 13
    
14.
Heinz TR, Vasconez LO. Fasciocutaneous Flaps for Elbow Coverage, Grabb′s encyclopedia of flaps. Upper extremity. 3rd ed. 2009 2. 661-667.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1]



 

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Introduction
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