Indian Journal of Plastic Surgery Medknow Publications on behalf of Indian Journal of Plastic Surgery ISSN: 0970-0358 EISSN: 1998-376x Vol. 44, Num. 1, 2011, pp. 59-67

Indian Journal of Plastic Surgery, Vol. 44, No. 1, January-April, 2011, pp. 59-67

Original Article

Reconstruction of severe hand contractures: An illustrative series

SC Tucker

Green Pastures Leprosy and Rehabilitation Hospital, Pokhara, Nepal,

Correspondence Address:
S C Tucker
Department of Plastic Surgery, Frenchay Hospital, Bristol BS16 1LE. U.K

sarahtucker@doctors.org.uk

DOI: 10.4103/0970-0358.81438

Abstract

Introduction

Severe contractures of the hand are a common problem for many reconstructive surgeons. A full assessment of the areas affected by the burn and the functional impairment caused is the first step towards providing appropriate surgical treatment. The two main areas that require a concerted effort to regain optimal function are proximal inter-phalangeal joint (PIPJ) contractures and dorsal contractures involving the Metacarpo-phalangeal joint (MCPJ). Proximal inter-phalangeal joint PIPJ flexion contractures were classified by Stern et al.^[1] into grades I, II and III. In grade I, the contracture at the PIPJ is correctable by passive flexion of the MCPJ, demonstrating that the problem is entirely limited to skin contracture. In grade II, the PIPJ flexion contracture is partially correctable with passive MCPJ flexion. In this case, the problem may be due to an excessive shortage of volar skin, but is likely to also involve the volar plate and collateral ligaments of the PIPJ to some extent. A grade III contracture is fixed at the PIPJ regardless of the position of the MCPJ. Here, there is a clearly significant involvement of the volar plate and collateral ligaments of the PIPJ, possibly with an element of actual joint destruction as well. In grade I contractures, the surgeon and patient can be optimistic of a good post-operative outcome following surgery that deals with the shortage of volar skin. In grade II contractures, the surgeon needs to be comfortable with the possibility that they may need to release the volar plate and the patient needs to be aware that full extension is not a guaranteed outcome In grade III, full extension is unlikely and the surgeon needs to be able to make a judgment between full release and joint stability and discuss the option of arthrodesis with the patient A careful assessment of the lateral slips of the extensor should be made; if they have subluxed volarward following attenuation of the central slip (as in a boutonniere deformity), then they must be addressed with the necessary splinting and/or surgery.

Secondary intention healing of unsplinted full-thickness burns to the dorsum of the hand frequently results in hyperextension contractures of the MCPJs, even if the burn area stops short of the dorsum of the joints themselves. The cam shape of the metacarpal head and the position of the collateral ligaments dorsal to the joint axis result in permanent shortening of the collateral ligaments even after relatively short periods of time in this position, particularly in the presence of the inflammatory response associated with the burn and secondary intention healing. Thus, release of the burn contracture to the skin alone is often not enough to correct this deformity, and release of the dorsal joint capsule and ulnar collateral ligament plus or minus release of the radial collateral ligament is required. The function of the hand is further compromised by the secondary effect that the MCPJ hyperextension has on the corresponding PIPJ [Figure - 1]. However, it can be seen from the cases discussed here that even in the face of such severe deformities as these, it is possible to regain a functional hand with radical surgery and intensive physiotherapy.

Presented here is a series of 44 cases of severe post-burn contractures of the hand. The author′s preferred options and decision making tree are discussed with illustrative cases, with particular reference to the difficult areas outlined above.

Materials and Methods

Between January 2007 and July 2008, 44 severely contracted burned hands in 42 patients were reconstructed by a single surgeon at Green Pastures Rehabilitation Centre, Pokhara, Nepal. The operating facilities at this hospital are basic, but well maintained, and the centre has very well established physiotherapy and occupational therapy services that are linked to a network of physiotherapists in the community that provide an outreach service.

The patients′ mean age was 14 years (range, 1-55), with an equal numbers of females and males.

All the contractures in this series caused functional impairment with limitation of movement by 60 degrees in at least two joints, or by 80 degrees in at least one joint. All the patients except one gave a history of a flame burn or contact burn occurring in early childhood that had only been treated with dressings. This other patient gave a similar history, but injury occurred in early adulthood. The delay from the burn to first presentation at this facility ranged from 9 months to 35 years. Three patients had had previous surgery; two with split skin grafts and one with a full-thickness skin graft.

All patients underwent release of the soft tissue element of the contracture, usually by incision of palmar contractures, and excision of contracted scar tissue for dorsal contractures.

[Table - 1] shows the reconstructive surgical options chosen in these patients. The largest single group is those treated with full-thickness skin grafts alone at 17 hands.

[Figure - 2] and [Figure - 3] show the reconstructive surgical decision-making algorithms drawn up towards the end of the time when there was an opportunity to reflect on the cases carried out and analyse the factors that had led to the options chosen. At the time that the majority of the clinical decisions were made, they were carried out on a case by case basis. But, on a retrospective review of the series, it became quite clear that there were consistent boundaries that triggered a decision to opt for a more complex reconstruction. These have been drawn up into a decision making tree to illustrate the process that was used in this series and to facilitate comparison with other practitioners.

Observations

There are several points that need highlighting, in that they differ slightly from other published series of burn contracture treatment.

In the case of the palmar contractures that are all distal to the distal palmar crease and too wide to be treated with a z pasty, the common description is of a transverse incision across the volar aspect of the PIPJ, ^[2] which opens up and is either skin grafted or covered with a cross-finger flap. In the series presented here, the initial transverse incision was made at the level of the midpoint of the proximal phalanx or at the junction of the palmar and digital skin, whichever was further distal. On reaching the midaxial line, the incision was extended both proximally and distally on both the ulnar and the radial borders of the finger, creating an H-shaped incision. With pressure applied to extend the finger, the midaxial incisions were continued until full soft tissue release was obtained. In effect, this created two flaps that "fell back," i.e. the opposite of advancement flaps, one based proximally and the other distally. The residual defect then underwent full-thickness skin grafting (these cases are simply recorded as full-thickness skin graft in the table of results). This approach had benefits over the simple transverse incision or a radical excision of all the scar tissue that were particularly advantageous in three situations. Firstly, where release of the joint had been required, coverage of the PIPJ with this flap meant that full-thickness skin graft was still an option for the residual soft tissue coverage without compromising graft take and outcome at the PIPJ. Secondly, where there was syndactyly caused by the scar contracture advancing the palmar skin, the process of allowing the flap to fall back reversed this and released the syndactyly. Thirdly, it kept the position of the resultant defect more proximal thus facilitating ease of placement of a flag flap or cross-finger flap if this was required. A flag flap was used in the index and middle fingers to avoid the need for a second procedure to divide the flap pedicle, with the attendant risk of stiffness following the required immobilization.

When the palmar defect was extensive, a reverse radial forearm fascial flap was used, covered with a split-skin graft. Alternative approaches here would be to use tissue expansion to increase the available full-thickness skin graft, to secondary graft the donor of a large full-thickness graft or to just use a split-skin graft. These options were not used here primarily because the radical excision of scarred tissue for full release of the contracture left a very uneven surface that was far from ideal for a skin graft, with some areas of tendon and nerve exposure. The assumed risk of applying a skin graft in these circumstances was that there would be some adhesions of the nerves and tendons and/or some skin graft loss, and this may have led to delayed healing and pain with consequent delay to the physiotherapy. The radial forearm fascial flap was chosen in order to allow gliding of the mobile structures in the hand and rapid, reliable take of the split-skin graft, with a much thinner soft tissue layer than would have been possible with a standard radial forearm flap. With this approach, it was possible to start gentle physiotherapy at just 5 days after the operation.

When the burn was on the dorsum of the hand and severe enough to cause hyperextension of the MCPJs, the contracted scar tissue was excised completely and, if necessary (three out of four cases in this series), the MCPJs were surgically released. This involved a longitudinal incision in the extensor tendon for exposure, dorsal capsulotomy, release of the ulnar collateral and, in one of the cases, also release of the radial collaterals. In all of these cases, there were areas of extensor tendon exposure without paratenon and, therefore, flap coverage was deemed necessary to hasten wound healing and facilitate the intensive physiotherapy necessary to regain functional movement in these severely affected joints. In two of these cases, the index finger was unsalvageable and therefore used as a fillet flap to cover the dorsal defect, wholly in one and in combination with a radial forearm flap in the other. At the time of flap insetting (fillet or reverse radial forearm or posterior interosseus artery flap), the MCPJs were held in flexion at 80 degrees with antegrade K wires through the metacarpal heads, reinforced with a volar slab applied at the end of the procedure. After 7-10 days, the K wires were removed and intensive physiotherapy was begun, with the volar slab worn between physiotherapy and occupational therapy activities for a further 2 weeks.

The issue of syndactyly release has been barely touched upon. This is because it was never done in isolation in these severe cases. Where syndactyly was a problem caused by the volar skin, it was either dealt with by allowing the palmar skin that had been dragged distally onto the digit to fall back towards the palm (see above) or the palmar aspect of the web spaces were resurfaced as part of a larger defect of the palm and digits. Where it was as a result of dorsal contracture, the excision of all the contracted scar tissue released the digits from one another, and the resulting soft tissue defect on the dorsal and lateral aspects of the fingers was resurfaced as part of the larger defect.

Results

There was one complete graft failure of a full-thickness skin graft that was treated with a split-thickness graft. There was one hematoma beneath a flap that required evacuation and one flap suffered skin necrosis of the distal tip for which debridement and split-skin grafting were carried out.

Fifty-one operative procedures were carried out, a mean of 1.1 per hand (procedures for bilateral problems were not carried out simultaneously). The seven procedures additional to the index procedure for each hand were: division of cross-finger flap in three cases, planned further procedures to transfer tendons, place an opening wedge osteotomy and bone graft (see case 2 below), one evacuation of hematoma and two salvage split-skin grafts. Thus, all but three of the operative procedures were planned, and the rate of complications requiring operative intervention was 6.8%.

The improvement seen by these patients is difficult to quantify; the resources available did not allow for pre- and post-operative functional testing. The most marked improvement was in those cases that presented with MCPJ hyperextension such that the fingers were unable to participate in hand function. In all these cases, the fingers were brought into a functional position with restoration of the normal resting position of the fingers and a functional range of motion at the MCPJs. The following cases illustrate the methods used and results obtained in this series.

Case 1

This was a 14-month-old female who had sustained a burn to the palmar surface of all digits of the right hand at age 4 months. It had been treated with dressings at the local health post until healed. No splinting had been used.

The index and little fingers had a Stern grade I contracture to the PIPJ [Figure - 4]. The middle and ring fingers had Stern grade II contractures [Figure - 5].

The index and little fingers were treated with z plasty, but in both cases additional skin was needed in the form of a full-thickness skin graft. After full release of the middle finger, the wound over the PIPJ was not ideal for a graft and, therefore, a flag flap was taken from the dorsum of the index and a full-thickness skin graft was applied to the secondary defect. In the ring finger, full release was possible with an ideal wound bed for a graft and, therefore, a full-thickness skin graft was sufficient for this digit [Figure - 6].

She was discharged with a volar resting splint to hold all the digits with the MCPJs and PIPJs in extension to be worn at night for at least 6 months and instructions to the parents to moisturize and massage the scars as they matured

Case 2

This was a 42-year-old male who had sustained burns to the left upper limb at the age of 4 years [Figure - 7], which had been treated with dressings at a local health post without the use of splinting. In the index procedure, he underwent release of contractures to the axilla, elbow and thumb and reconstruction with a combination of local flaps and split-skin grafting to the secondary defects. After this, he had a good range of motion at the axilla and 80-110 degrees at the elbow, but the thumb was unstable and unable to come into opposition with the other digits. He therefore underwent an opening wedge osteotomy of the trapezium with iliac bone graft insertion and FDS opponensplasty. This provided him with a stable thumb for use in grasping, which was able to meet the other digits, but opposition to the little finger was only to the tip [Figure - 8].

Case 3

This 12-year-old female sustained a deep burn to the dorsal surface of her hand in infancy. It was treated with dressings and allowed to heal by secondary intention without the use of any splinting, and resulted in hyperextension of the MCPJs, compensatory flexion of the PIPJs and abduction of the little finger. The entire lengths of all her fingers were positioned dorsal to the metacarpals so that they were unable to participate in hand function in any way [Figure - 9]. The dorsal longitudinal structures seen have the appearance of bowstringing of the extensor tendons, but are in fact tight bands of skin where the skin of the dorsum of the digits has been pulled back onto the dorsum of the palm, the extensors remaining close to the bones and joints by virtue of their connections with the intrinsic muscles via the sagital bands.{Figure 9}

She underwent excision of the scar tissue, following which manipulation of the MCPJs was found to be sufficient to obtain 0-90 degrees of flexion [Figure - 10]. There were areas of tendon exposure without paratenon and soft tissue cover was therefore carried out with a reverse radial forearm flap [Figure - 11] and [Figure - 12]. She commenced physiotherapy 5 days after the operation. Her resting position showed restoration of the normal cascade of finger flexion, except that the little finger had an extensor lag of 10-20 degrees, which persisted on active flexion for fist formation. She was able to form a fist and all digits participated in hand function. Even at this early stage, she was extremely pleased with the improved appearance and functioning of this hand.

Case 4

This 20-year-old female sustained a deep burn to the palm of her hand in her early childhood that was treated with dressings and allowed to heal by secondary intention without splinting. The IPJ of the thumb was deviated 90 degrees in a radial direction, with underlying bony abnormality of the joint. The index finger had a PIPJ contracture Stern grade II, the middle and ring fingers had autoamputated at the distal third of the proximal phalanx with the remnants being buried into the palm and the little finger was flexed, abducted and also buried in the palm [Figure - 13].

She underwent full excision of the contracted scar tissue, releasing the digits from the palm, and arthrodesis of the IPJ of the thumb into a functional position. The resulting soft tissue defect included the proximal half of the palmar surface of the thumb, the whole palmar surface of the middle ring and little fingers and the whole of the palm other than a small strip proximally. The wound surface on the palm was very uneven, with some areas of exposure of the flexor tendons and common digital nerves. A skin graft here would probably have had islands where it failed and may have tethered these structures, with a resultant limitation on the mobility of the digits. The option chosen here was a reverse radial forearm fascial flap covered with a thick sheet split-skin graft to allow gliding of the exposed tendons and nerves beneath the fascial layer and an ideal wound bed for skin graft take.

At her first dressing change 5 days later, she was seen to have 100% take of the skin graft and gentle physiotherapy was initiated with the use of a resting splint between the therapy sessions [Figure - 14]. The physiotherapist planned to make a volar-based resting splint for her to wear at night for the next 6 months once the wound was completely settled.

Discussion

Severe burn contractures are a difficult problem for the reconstructive surgeon and require intensive input from the therapy staff. The cases in this series were all severe enough to have caused limitation of joint movement by 60 degrees or more in at least two joints, or 80 degrees or more in at least one joint. Many of them had Stern grade III contractures of at least one digit, autoamputation of finger tips or digits deviated outside of the normal range of motion. The approach taken to the release of these contractures was to release all soft tissue that restricted movement and to return all joints back to a functional position, accepting that in some cases this entailed either arthrodesis or a limited but functional range of motion The cultural environment in this series was such that amputation was only accepted by the patient if the digit was clearly going to interfere with hand function. The soft tissue aspect of the release usually required incision of the scar tissue for palmar contractures and excision of contracted scar tissue on the dorsum. The soft tissue reconstruction in just over half of the cases was with a split- or full-thickness skin graft; however, it is far from the case that these are simple cases that "just need a skin graft." Good surgical judgment and a sound knowledge of the available flaps are needed to identify and successfully treat those hands that will benefit from flap coverage. Some form of flap was used in 19 of the hands in this series, with those that had a flap to the dorsum of the hand following correction of hyperextension of the MCPJs seeing the most marked improvement in function. The aesthetic appearance of these hands was also markedly improved, more so than would have been the case with the use of a skin graft. The results seen here are a credit to the dedication and expertise of the physiotherapy and occupational therapy staff. Caution should be taken when reconstructing these cases without the availability of hand therapists as this is likely to limit the possible outcomes.

The cultural environment that this work is carried out in must be understood by the clinician making the management decisions in these cases. In the series presented here, the patients were from remote regions and lived on subsistence farming. Compliance with physiotherapy and attendance at clinics after discharge from hospital was therefore likely to be poor, and the surgical options chosen were with a view to providing a robust result in a single hospital admission. Pensler et al.^[3] compared full-thickness skin grafts with split-thickness skin grafts for reconstructing the palms of 25 children with follow-up of between 3 and 9 years duration. Their results showed that 1.2 operations per hand were required for the split-thickness skin graft group and 1.3 per hand for the full-thickness group. Although this shows no significant difference for the two groups, it does illustrate that at least every fifth child had recurrence that merited re-operation in their series. When they analysed the figures for those cases with more than 75% of the palm involved, the number of operations required were 1.5 per hand for split-thickness and 1.2 per hand for full-thickness. Although this did not reach statistical significance, the numbers were extremely small and, therefore, a larger sample would be needed to see whether this clinically significant difference was born out in a larger group. Many authors advocate the use of flaps in reconstructing the burned hand in order to reduce the recurrence rate. ^[4],[5] Local and regional flap choices include the dorsal ulnar flap for palmar defects up to the bases of the digits, ^[4] the posterior interosseus artery flap, which can be used as far as the MCPJs, or in a two-stage procedure to cover defects extending on to the fingers,^[6] the reverse radial forearm flap, ^[7] the reverse ulnar forearm flap, radial artery perforator flap ^[7] and ulnar artery perforator flap. ^[8] Free flaps that have been recommended for use in reconstruction of the burnt hand include the medial plantar artery flap for palmar defects, ^[5] the anterolateral thigh perforator flap, either as a fasciocutaneous flap or adipofascial flap with skin graft, ^[9] the serratus fascia flap with split-thickness skin graft ^[10] and the temporoparietal fascial flap with split-thickness skin graft. ^[11]

The use of flaps not only imports vascular tissue but also allows for the incorporation of a fascial layer between the mobile gliding structures and the skin. This is recognized to improve the mobility of the hand because it reduces the occurrence of adhesions between the tendons and the skin. ^[9],[10] Hence, the common factor in all the above flaps is the use of the fascial layer in this manner, whether as part of a fasciocutaneous flap or a fascial flap that is skin grafted.

In the series reviewed here, the use of free flaps was not an available option for a combination of reasons; there was no microscope, an anaesthetist was only available for one or two sessions per week and therefore most cases were carried out under brachial blocks or ketamine provided by a non-anaesthetist and the pressure on operating time was such that a free flap would have meant turning other patients away. Therefore, regional flaps that would provide similar tissue to that available for free transfer were chosen. The posterior interosseous flap is preferable to the radial forearm flap in that it does not require the sacrifice of the radial artery. However, as a one-stage procedure, it only reaches the MCPJs. Puri et al.^[6] showed that including a wide cuff of fascia around the artery improved venous drainage and the safety of this flap, and this is to be recommended. They also demonstrated that the reach of this flap could be improved by exteriorizing the pedicle with the wrist in extension, dividing the pedicle at a second stage 3 weeks later. This was not attempted in the current series because the flap was being used in cases where early physiotherapy to regain flexion of all joints was a very important element of the treatment. The radial and ulnar artery perforator flaps would have been an option, but the author was not familiar with them at the time, and the prolonged operating time for locating and islanding the perforators may deter some surgeons from using them in these settings. The fasciocutaneous radial forearm flap is well established in the reconstruction of the hand, providing supple thin tissue of good match to the normal dorsal skin of the hand. The choice to use it as a fascial flap with split-skin graft in the palm arose from the need for a very thin flap in order to maximize the ability of the palm to cup objects. The use of fascial flaps with split-skin grafts is a recognized option that is commonly used when free flaps are available with all the options that this releases.^[10] Long-term follow-up is lacking and therefore it has not yet been determined whether the split-skin graft onto the fascial flap will contract to the extent that a split-skin graft on its own would.^[11] There have been a couple of cases with follow-up over 3 years, neither of which have shown contracture formation, and it is hoped that the rapid graft take and good gliding provided by this method that facilitate early aggressive physiotherapy may help to prevent recurrent contracture formation.

It is impossible to discuss these reconstructions without passing comment on the need for improved early burns management that could prevent the secondary contractures from occurring. In hospitals where burns to the hand are treated in the acute stage by multidisciplinary teams with intensive input from surgeons, physiotherapists and occupational therapists, 97% of the patients with superficial injuries and 81% with deep dermal injuries will have normal hand function at the end of their treatment.^[12] Unfortunately, this is not the case globally and, in many parts of the world, this remains an unrealized aspiration, with resources for the treatment of acute burns being scarce at best. Additionally, in resource-poor areas, the epidemiology of burns is markedly different, with a greater proportion being flame related, deeper burns due to poor heating and cooking facilities. Subsequently, in these areas, there continues to be a steady flow of patients seeking surgical treatment for severely deformed hands, providing reconstructive surgeons with a significant challenge.

In essence, it is important that patients with such severe post-burn contractures, some of whom would benefit from a flap, are treated by a surgeon who has mastered a range of flaps that will cover the hand, within a setting where there is hand physiotherapy expertise available. Although such facilities may mean travelling significant distances for these patients, it is still preferable for them to have a single hospital admission, the aim of which is to return them to a financially productive level of function for the rest of their life.

References

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