Burn Contracture Surgery Stuart Watson Canniesburn Unit Glasgow Royal Infirmary Glasgow United Kingdom [email protected] 1 Table of Contents Prevention of Contractures ................................................................................................. 4 Contracture Definitions ....................................................................................................... 4 Timing of Contracture Surgery: Indications ....................................................................... 5 Urgent ............................................................................................................................. 5 Early ................................................................................................................................ 5 Late ................................................................................................................................. 5 General Principles and Technical Tips ............................................................................... 6 Approach to Contracture Surgery ....................................................................................... 8 Split Skin Grafts .................................................................................................................. 8 Full Thickness Grafts .......................................................................................................... 9 Dermal Substitutes .............................................................................................................. 9 Locals Flaps ...................................................................................................................... 10 Free Flaps .......................................................................................................................... 10 Tissue Expansion .............................................................................................................. 11 Techniques used in Different Anatomical Sites: Important Note ..................................... 11 The Hand ........................................................................................................................... 13 General Principles ......................................................................................................... 13 Local Flap “Plasties” in the Hand ................................................................................. 13 Underlying Principles ................................................................................................... 13 Five Flap Z plasty ......................................................................................................... 13 Z-plasty ......................................................................................................................... 14 Y to V Plasty ................................................................................................................. 14 Skin Grafting and Flaps for Hand Contractures ........................................................... 14 Palmar surface—Flexion Contractures ......................................................................... 14 The PIP Joint-flexion deformity ................................................................................... 17 Extensor Surface---extension contractures ................................................................... 17 Skin grafting .................................................................................................................. 17 Severe Dorsal Contractures (role of flaps) .................................................................... 17 Interdigital web contractures ......................................................................................... 18 Square Flap Design ....................................................................................................... 18 The Axilla ......................................................................................................................... 19 Procedures for linear band contractures ........................................................................ 19 Perforator Based Flaps for Axilla ................................................................................. 20 Medial Arm Flap for Thick anterior axilla/shoulder band ............................................ 20 Posterior arm flap .......................................................................................................... 21 Procedures for Diffuse Axillary contractures ............................................................... 21 Flaps: ............................................................................................................................. 21 Grafting: ........................................................................................................................ 22 Trapezoid Flap plus grafting: ........................................................................................ 22 Linear Band Contractures--- Z plasty ........................................................................... 24 The Neck…………………………………………………………………………………22 Diffuse (broadband) Neck Contractures ....................................................................... 25 Flaps for Neck Contractures ......................................................................................... 26 Antecubital fossa ............................................................................................................... 27 Local Flaps for mild/moderate scarring ........................................................................ 27 2 Propeller Flap or Island Perforator-Based Flap ............................................................ 28 Diffuse contractures of Antecubital Fossa .................................................................... 29 The Olecranon ................................................................................................................... 30 The Wrist .......................................................................................................................... 31 The Face ............................................................................................................................ 32 The eyelids .................................................................................................................... 32 The Mouth ..................................................................................................................... 33 Anaesthesia ................................................................................................................... 34 The Groin and Perineum ................................................................................................... 35 Perineum ....................................................................................................................... 36 Popliteal Fossa and Knee .................................................................................................. 37 The Foot and Ankle .......................................................................................................... 38 Dorsum .......................................................................................................................... 38 Sole and Tendo Achilles ............................................................................................... 40 Final Notes ........................................................................................................................ 40 Recommended Further Reading ....................................................................................... 40 3 Prevention of Contractures Many burn scar problems can be prevented by appropriate intervention and work from the burns multidisciplinary team (which includes the patient) Typical interventions include the following Nurses: Prevention of infection Encourage mobilization Surgeons: Skin grafting to achieve early healing Patient and family: Compliance with exercises, massage, splints and pressure garments Physiotherapist/occupational therapist: Crucial role in encouraging and providing physical rehabilitation; instilling determination and compliance with rehabilitation regime in the patient and family. Manufacture and fitting of splints, moulds, silicone and pressure garments for scar therapy. Anaesthesia/Pain management: Providing physical comfort so that patient can mobilize stiff joints. Contracture Definitions Intrinsic contracture: a contracture where scarring directly involves the site affected by contraction Extrinsic contracture; a contracture of normal structures that are pulled out of position by scarring distant to the site. A typical example of this is a normal lower eyelid pulled into ectropion by scarring on the cheek. Linear band contracture: a band of scar tissue surrounded by relatively normal skin. This is readily treatable by local flap plasties with or without band excision. Linear band contracture in diffuse scarring; The skin surrounding a band contracture is scarred and Z plasties that require flap elevation carry a high risk of necrosis. Y to V plasties that do not require flap elevation may be an option. However, in scarred skin, the Y-V plasties may simply move the site of the troublesome band to an adjacent area, and a larger flap or graft may be required instead. Broadband contracture: The contracture involves the whole of an anatomical surface and requires an incisional release or excision with inset of flap