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Elbow and Wrist Burn Reconstruction
4.7 Elbow and Wrist Burn Reconstruction Lauren Hewell Fischer, Shankar Man Rai
SYNOPSIS Burns continue to be a significant source of morbidity and mortality in low- and middle-income countries. Patients that survive the original injury often develop burn scar contracture because burns across the neck, axilla, elbow, and wrist are forced to heal by secondary intention. The physical examination is the most important part of evaluating a patient with wrist or elbow contracture. The surgeon must identify scar bands causing contracture, inspect soft tissue quality surrounding the joint, and examine donor sites (groin, back, thighs, etc.) for possible grafts and/or flaps. Local tissue, compared with skin grafts, is preferable for joint resurfacing after contracture release, as it is more resistant to recurrent contracture. Compliance with splinting and postoperative physiotherapy is paramount in preventing recurrent burn scar contracture.
CLINICAL PROBLEM According to the World Health Organization, burns account for an estimated 265,000 deaths every year, the majority of which occur in low- and middle-income countries.1 Those who survive the acute burn injury often suffer significant lifelong morbidity. Burn patients living in remote villages do not have easy access to health care, let alone the specialized resources necessary to acutely treat a burn. Without early burn excision and skin grafting, splinting, and physiotherapy, burn scar contracture is inevitable for patients with deep partial-thickness and full-thickness burns. Although the ultimate solution for preventing burn scar contracture is to eradicate all burns, this is not today’s reality. Flame burns occur commonly because people of all ages are exposed to open flames for cooking, warmth in the home, and prayer. Whereas women and children are more likely to sustain flame or scald burns related to cooking in the home, men are more likely to sustain flame, scald, electrical, or chemical burns in the workplace. Most cases of post-burn scar contracture present years to decades after the original burn injury. It is common to see teenage patients with burn scar contracture, possibly reflecting the high incidence of burn injuries sustained by children at home; the teenagers are now of working age and desire a functional limb. The patient will present with a gross deformity and limited range of motion about the affected joint. Epilepsy can be associated with post-burn scar contracture because patients can fall into flames and/or scalding liquids during a seizure. More commonly associated conditions include malnutrition and anemia.
PRE-OPERATIVE MANAGEMENT The physical examination is the most critical component of the preoperative management of a patient with post-burn contracture of the
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elbow or wrist. The elbow is most commonly contracted in a flexed position, whereas the wrist can be contracted in either a flexed or an extended position. Dorsal hand/wrist burns cause contracture of the wrist in hyperextension, whereas volar hand/wrist burns cause contracture of the wrist in flexion. Examine the involved joint, identify scar bands, assess range of motion, and document the degree of flexion or extension contracture. Inspect the quality of the soft tissue surrounding the scar bands causing joint contracture to determine whether local tissue can be used for resurfacing the joint after contracture release. Also assess the patient’s groin, thighs, back, chest, and abdomen, because these areas may be necessary donor sites for skin grafts and/or flaps. Examine joints proximal and distal to the involved joint because patients with elbow joint contracture can have concomitant axillary and wrist contractures, and digit contractures commonly occur with wrist contractures. Pre-operative testing needs are minimal for patients undergoing post-burn contracture release. A plain radiograph, if available, to assess the integrity of the affected joint can help the surgeon plan appropriately for surgery. The presence of growth abnormalities from prolonged joint contracture, heterotopic ossification, and so on, can result in marked range-of-motion restrictions that will not be corrected by soft tissue scar release alone. A hemoglobin concentration can be useful if an extensive surgery is planned due to the prevalence of associated anemia in low- and middle-income countries. The upcoming surgery can also be used as a time to screen patients for blood-borne infectious disease such as hepatitis B, hepatitis C, and HIV/AIDS because many people do not have routine access to health care/screenings. Surgery should not be delayed in children because prolonged joint contracture can restrict growth of the joint and surrounding long bones, causing significant functional impairment. Additionally, the social stigmata of burn scar contracture can have a lifelong psychological impact on young patients. If no other more pressing medical or surgical issues exist, release of the joint near the time of presentation can help the patient to develop more normally and to reintegrate into society in a timely fashion. Supplies necessary for surgery include surgical instruments, suture, soft dressings, and splinting materials. Only 5 surgical instruments are critical for this case: a scalpel with #10 or #15 surgical blade, a forceps (preferably Adson), skin hooks (single or double), dissecting scissors (Littler or tenotomy), and a needle holder. A monopolar or bipolar electrosurgery unit is necessary to achieve hemostasis. If one of these units is not available, a handheld electrocautery device can be used instead. A tourniquet, if available, can be helpful for extremity surgery because it facilitates safe dissection by creating a bloodless field, and minimizes overall blood loss during the operation. A dermatome is useful if the case requires a split-thickness skin graft, but it is not absolutely necessary because a graft can be harvested with a handheld knife.
CHAPTER 4.7 Elbow and Wrist Burn Reconstruction When choosing suture, use what is available. 3-0 or 4-0 absorbable suture can be used to secure deep tissue, and 3-0 or 4-0 chromic gut or plain gut can be used for the skin. Preferentially use absorbable sutures (chromic gut or plain gut) instead of permanent sutures (nylon or silk) when performing elbow/wrist burn scar contracture release in children to avoid the fear and perceived/real pain associated with suture removal in children. Dressings should include emollient gauze and 4×4s. The splint is arguably the most important part of the operation because failure to splint the patient in the appropriate post-operative position can lead to early recurrence of joint contracture. To fashion a proper splint, the surgeon will need plaster or fiberglass splint material and cotton cast padding. It is critical to use some form of cast padding to prevent pressure wounds from an ill-fitting splint. The choice of general anesthesia versus local anesthesia, with or without sedation, is largely determined by the patient’s age and the extent of surgery that is planned. If the patient has a neck contracture, release the neck contracture under local anesthesia before inducing general anesthesia or giving any sedatives. It is extremely difficult to intubate a patient with a neck contracture, so the contracture must be released before intubation.2 A child should be at least 3 months of age to safely undergo general anesthesia. It is reasonable to test a serum alkaline phosphatase level pre-operatively if the patient will undergo general anesthesia and has had general anesthesia in the past because some inhalation anesthetics can have the side effect of elevated serum alkaline phosphatase levels. Several local anesthetics are acceptable for joint contracture release, including lidocaine, with or without epinephrine, and bupivacaine, with or without epinephrine. Bupivacaine is less preferable due to its increased cardiotoxicity compared with lidocaine and its unknown effects in children under the age of 12. Remember the following cumulative safe doses for the aforementioned local anesthetics: Lidocaine (0.5% or 1%) with 1 : 200,000 epinephrine—7 mg/kg Lidocaine (0.5% or 1%) without epinephrine—4 mg/kg
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FIG. 4.7.1 Ulnar deviation of the wrist and hyperabduction of the ulnarmost digit caused by scar tissue along the dorsoulnar hand and wrist— dorsal view.
SURGERY During the pre-operative physical examination, prominent scar bands causing elbow or wrist contracture are identified. Additionally, the quality of soft tissue surrounding the joint should be assessed. One should be fully aware of critical structures that may be injured during scar contracture release. At the level of the elbow, there are several critical structures that may be closely adhered to the overlying scar. The brachial artery and median nerve lie just underneath the lacertus fibrosus. The biceps tendon, critical for active elbow flexion, may become the limiting structure preventing further elbow extension. This should not be transected. At the level of the wrist, critical volar structures include the median nerve and radial nerve, which are fairly superficial. The ulnar artery and ulnar nerve lie protected underneath the flexor carpi ulnaris tendon, but they are still at risk in deep burn contractures. The patient in Figs. 4.7.1 and 4.7.2 has a post-burn contracture of the right hand and wrist that is causing ulnar deviation of the wrist and hyperabduction of the ulnar-most digit. The scar band along the ulnar aspect of the wrist and hand is responsible for this contracture. The remaining skin of the dorsal and volar hand and wrist is soft and mobile. This indicates that local tissue rearrangement in the form of several Z-plasties is the preferred method for contracture release and soft tissue coverage. The four fundamental functions of a Z-plasty are to lengthen a scar, to break up a straight line, to move tissues from one area to another, and to obliterate or create a web or cleft (Table 4.7.1).3 Local flaps should be utilized as much as possible because they have a lower incidence of recurrent contracture compared with skin grafts and do not require an additional donor site.4
FIG. 4.7.2 Volar view.
TABLE 4.7.1 The Four Fundamental
Functions of Z-Plasty
1. To lengthen a scar 2. To break up a straight line 3. To move tissues from one area to another 4. To obliterate or create a web or cleft Reproduced from Lorenz P, Bari AS. Scar prevention, treatment, and revision. In: Neligan P, Gurtner GC, eds. Plastic Surgery. 3rd ed, vol 1. London: Elsevier Saunders; 2013.
Z-plasties are designed over the scar band. Think of the scar band as the central portion of the Z-plasty with the limbs of the “Z” placed on either side of this central scar band. When designing Z-plasties, remember that all limb lengths must be equal. A 60-degree angle gives a theoretical gain in scar length of 75% (Table 4.7.2). Several Z-plasties designed in series will help release the contracture by adequately lengthening the scar.
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TABLE 4.7.2 Z-Plasty Gains in Length Angle of Lateral Limb of Z-Plasty 30 45 60 75 90
Theoretical Gain in Length of Central Limb (%) 25 50 75 100 120
Reproduced from Lorenz P, Bari AS. Scar prevention, treatment, and revision. In: Neligan P, Gurtner GC, eds. Plastic Surgery. 3rd ed, vol 1. London: Elsevier Saunders; 2013.
Local anesthesia is injected in the areas of planned incision. A tourniquet, if available, is applied to the forearm or upper arm for wrist contracture release. The patient will better tolerate the tourniquet on the forearm compared with the upper arm for wrist surgery if he or she is awake, and the arm is not blocked with a regional anesthetic. Cases of elbow contracture release will require placement of the tourniquet on the upper arm. The tourniquet is inflated to 100 mm Hg above the patient’s systolic blood pressure to help prevent excessive pressure on the arm, which can lead to neuropraxia. The skin along the planned markings is incised using a #10 or #15 surgical blade. Each flap is elevated off of underlying muscles and tendons (Fig. 4.7.3). Each flap should contain skin and subcutaneous tissue and should be left thick to improve the vascularity, and ultimate viability, of the flap. Single or double skin hooks can be used for retraction. Flap elevation can be performed with a scalpel or dissecting scissors. Most critical neurovascular structures are deep to the plane of dissection. In this case the ulnar artery and nerve will be protected beneath forearm muscles/tendons; however, one must watch for the dorsal sensory branch of the ulnar nerve during dissection. Depending on the location of the wrist or elbow contracture, other commonly encountered cutaneous nerves include the palmar cutaneous branch of the median nerve, the dorsal sensory branch of the radial nerve, the lateral antebrachial cutaneous nerve, and the medial antebrachial cutaneous nerve. The position of the wrist and digits is evaluated to ensure that the contracture has been adequately released before insetting the flaps. In this case, dorsal and volar views of the hand and wrist demonstrate that the wrist is now neutral in the radial-ulnar plane and that the ulnar-most digit is no longer hyperabducted (Figs. 4.7.4 and 4.7.5). Kirschner wires (K-wires) can be used as internal splints for digits if available. Splinting of the proximal interphalangeal joint is avoided, if possible, to prevent stiffness of the digit. Hemostasis is achieved with a monopolar or bipolar electrosurgery unit or handheld electrocautery device. Adjacent triangular flaps are rearranged. The flaps must be transposed to achieve the desired lengthening effect (Fig. 4.7.6). The flaps are secured in the correct orientation using a few interrupted, buried, deep-dermal 3-0 or 4-0 sutures. The skin is closed with 3-0 or 4-0 chromic gut or plain gut simple or mattress, interrupted sutures. Figs. 4.7.7, 4.7.8, and 4.7.9 demonstrate the patient’s hand with healthy soft tissue across the wrist and ulnar-most metacarpophalangeal joint after local tissue rearrangement. If a soft tissue deficit exists after insetting the flaps, a full-thickness skin graft can be harvested from the groin, lower abdomen, or antecubital fossa. The graft should be sufficiently defatted to enhance its “take.” Raw surfaces are covered with the full-thickness skin graft and sutured in place using 3-0 or 4-0 chromic gut or plain gut suture. If a large soft tissue deficit exists after flap inset, a split-thickness skin graft may be harvested from the anterior thigh or any other available donor site. The
FIG. 4.7.3 Flap elevation off of the underlying muscles and tendons.
FIG. 4.7.4 Correction of contracture after scar release. Note the use of K-wire for internal splinting—dorsal view.
FIG. 4.7.5 Volar view.
CHAPTER 4.7 Elbow and Wrist Burn Reconstruction
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Tension
60°
FIG. 4.7.7 Healthy soft tissue surrounding the original burn scar allows for wound closure via Z-plasties.
75% gain in length
FIG. 4.7.8 Volar view.
FIG. 4.7.6 Z-plasty technique. (Reproduced from Lorenz P, Bari AS. Scar prevention, treatment, and revision. In: Neligan P, Gurtner GC, eds. Plastic Surgery. 3rd ed, vol 1. London: Elsevier Saunders; 2013.)
FIG. 4.7.9 Ulnar view.
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dermatome is usually set to 0.012 to 0.016 inch. The split-thickness skin graft can be used as a sheet graft. Meshed split-thickness skin grafts are avoided, if possible, because their interstices heal by secondary intention and can cause recurrent contracture. Accumulation of hematoma and/or seroma under a skin graft will impede its ability to survive. Quilting sutures throughout the graft can improve graft survival by decreasing the dead space between the graft and the wound bed. Additionally, tie-over bolster dressings improve the surface contact between the graft and wound bed by applying constant pressure to the graft.
POST-OPERATIVE CARE The bolster component of the “tie-over bolster dressing” can be created by wrapping a ball of cotton moistened by mineral oil in a piece Xeroform or other emollient gauze. The bolster should be large enough to cover the entire skin graft, and is normally secured to the skin surrounding the skin graft using 4-0 nylon or silk suture. The remaining incisions should be covered with Xeroform or another form of emollient gauze. After release of wrist contractures, the hand is splinted in the intrinsicplus position, with the wrist in 30 degrees of extension. If a contracture release of the dorsal wrist is performed, it is acceptable to splint the wrist in a more neutral position (less than 30 degrees of wrist extension) to help prevent recurrent contracture of the wrist. Elbow flexion contractures should be splinted in full extension post-operatively.5 Antibiotics that cover skin flora for 1 week post-operatively may be given prophylactically to help prevent surgical site infection. The splint that was applied immediately after surgery should be worn 24 hours a day by the patient and is normally removed on post-operative day 5. The splint should be removed immediately and all surgical sites evaluated if the patient develops a fever or erythema of the upper extremity. If a skin graft was not used, no further dressings are needed after splint removal, and the incision lines can be left open to air. If a skin graft was used, the tie-over bolsters are removed on post-operative day 5. The grafts are then cleaned with normal saline daily, and a small amount of bacitracin ointment is applied daily until all wounds have healed. Steri-Strips or suture strips can be used, if available, to reinforce the skin closure at the fullthickness skin graft donor site until the Steri- or suture strips fall off. A hand therapist should see the patient on post-operative day 5 at the time of the first dressing change. Fabrication of an orthoplast splint at this time will help facilitate daily dressing changes. Range-of-motion exercises and use of the affected extremity for activities of daily living can begin at 2 weeks post-operatively if skin grafts are stable and the incisions are healing well. The patient should be instructed to wear the removable splint 24 hours a day, 7 days a week, for 2 to 3 months, removing it only to change dressings and to work on therapy exercises. The hand therapist can also help educate family members on the importance of splint compliance, and on the safe application and removal of the splint. After 2 to 3 months, the hand therapist will determine whether it is appropriate for the patient to transition to nighttime-only splint use. Return to work should be determined on a caseby-case basis because this decision depends on a multitude of factors.
MANAGEMENT OF COMPLICATIONS The most common complication of burn scar contracture release is recurrence of contracture.6 The patient will present with decreased range of motion at the site of previous contracture release and with a visible scar band that limits range of motion. To address the recurrent contracture, the wrist (or elbow) contracture is re-released and a different surgical option for soft tissue coverage is planned. Often, recurrent contracture occurs because of patient noncompliance with post-operative splinting protocols. To prevent recurrent contracture from lack of
FIG. 4.7.10 Soft tissue is preserved directly over the dorsal wrist joint.
FIG. 4.7.11 The remaining large soft tissue defect is covered with a split-thickness sheet graft.
splinting, patient compliance with splinting and physiotherapy protocols must be ensured before embarking on another operation. Using a split-thickness skin graft for recurrent contractures can be considered if the soft tissue defect is large and a split-thickness skin graft was not previously used. If possible, the patient’s native soft tissue is left directly over the joint because it is more resistant to contracture than the skin graft (Figs. 4.7.10 and 4.7.11). Suture lines directly over joints are avoided because they can promote contracture. In severe cases of dorsal wrist/hand contracture, the extensor tendons may require tenotomy (stair-step) for lengthening or even complete transection. The retrograde posterior interosseous artery (PIA) flap can transfer supple soft tissue from the dorsal forearm to open wounds of the dorsal or volar wrist when recurrent contracture occurs because Z-plasties and skin grafts have failed. The flap is based distally on the PIA, which is located between the extensor digiti minimi (EDM) in the 5th extensor compartment and the extensor carpi ulnaris (ECU) in the 6th extensor compartment.7 The retrograde perfusion of this flap is dependent on the distal communication between the anterior interosseous artery (AIA) and the PIA just proximal to the distal radioulnar joint (DRUJ). This connection is absent in approximately 5% of people, so it is important to explore the pedicle before full flap elevation.
CHAPTER 4.7 Elbow and Wrist Burn Reconstruction
A
B
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C
FIG. 4.7.12 (A) Incision planning for a posterior interosseous artery (PIA) flap. (B) Elevation of the PIA flap and closure of a larger fasciocutaneous donor site with a split-thickness skin graft. (C) Rotation of the PIA flap to reconstruct a moderate-size ulnar palmar defect. (Reprinted from Page R, Chang J. Reconstruction of hand soft-tissue defects: alternatives to the radial forearm fasciocutaneous flap. J Hand Surg Am. 2006;31A(5):847-855.)
The axis of the flap is along a line joining the lateral epicondyle of the elbow and the DRUJ. A perforator of the PIA, located at the midpoint of this axis, should be included in the flap design. The reliable proximal limit of the flap is 6 cm distal to the lateral epicondyle. The pivot point is 2 cm proximal to the DRUJ (Fig. 4.7.12). Flap elevation should begin with exploration of the pedicle through a curvilinear incision, along the axis of the flap, located between the pivot and the planned distal border of the flap. The PIA will be located on the interosseous membrane at the base of the septum between the EDM and ECU tendons. If the distal PIA is absent and the distal communication with the AIA is absent, the procedure is discontinued. The ulnar border of the flap is incised, and the flap is elevated subfascially toward the septum. The radial border is elevated next. With the tourniquet deflated, an atraumatic clamp is applied to the proximal pedicle to assess distal perfusion to the flap before dividing the proximal pedicle. The flap can be used to cover defects of the dorsal or volar wrist. In cases of recurrent post-burn contracture of the elbow, a distally based lateral arm flap can be used to resurface the volar elbow joint.8 Although the distally based PIA flap and the distally based lateral arm flap are ideal axial flaps for wrist and elbow contracture, respectively, less complex flaps can be used to bring healthy tissue over a joint. The pedicled groin flap can be used for the wrist, and a random-pattern skin/subcutaneous tissue flap from the trunk can be used for the elbow. These flaps are reliable and easy to harvest; however, they require patient compliance during neovascularization of the flap (the patient is tethered to the groin or chest for 3 weeks before flap division and inset) and during post-operative physiotherapy for joint stiffness.
KEY REFERENCES 1. World Health Organization. Burns fact sheet. http://www.who.int/ mediacentre/factsheets/fs365/en/. Accessed January 12, 2017.
KEY PRINCIPLES • Never create a longitudinal (straight line) incision across the flexor surface of a joint. The resultant scar will cause joint contracture. • Utilize local flaps as much as possible to resurface raw surfaces after joint contracture release. • Avoid use of split-thickness skin grafts over joints if possible. Full-thickness skin grafts have less secondary contracture than split-thickness grafts and leave a better donor site scar. • Use quilting sutures and bolster dressings to help prevent hematoma/seroma under skin grafts. • Splint post-operatively to prevent recurrent joint contracture.
2. Kreulen M, Mackie DP, Kreis RW, et al. Surgical release for intubation purposes in postburn contractures of the neck. Burns. 1996;22(4):310–312. 3. Lorenz P, Bari AS. Scar prevention, treatment, and revision. In: Neligan PC, Gurtner GC, eds. Plastic Surgery. vol. I. 3rd ed. St. Louis, MO: Saunders Elsevier; 2005:297–318. 4. Schwarz RJ. Management of postburn contractures of the upper extremity. J Burn Care Res. 2007;28(2):212–219. 5. Borghese L, Masellis A, Masellis M. Extremity burn reconstruction. In: Neligan PC, Chang J, eds. Plastic Surgery. vol. VI. 3rd ed. St. Louis, MO: Saunders Elsevier; 2005:435–455. 6. Balumuka DD, Galiwango GW, Alenyo R. Recurrence of post burn contractures of the elbow and shoulder joints: experience from a Ugandan hospital. BMC Surg. 2015;15:103. 7. Page R, Chang J. Reconstruction of hand soft-tissue defects: alternatives to the radial forearm fasciocutaneous flap. J Hand Surg Am. 2006;31A(5):847–855. 8. Turegun M, Nisanci M, Duman H, et al. Versatility of the reverse lateral arm flap in the treatment of post-burn antecubital contractures. Burns. 2005;31:212–216.
SYNOPSIS Burns continue to be a significant source of morbidity and mortality in low- and middle-income countries. Patients that survive the original injury often develop burn scar contracture because burns across the neck, axilla, elbow, and wrist are forced to heal by secondary intention. The physical examination is the most important part of evaluating a patient with wrist or elbow contracture. The surgeon must identify scar bands causing contracture, inspect soft tissue quality surrounding the joint, and examine donor sites (groin, back, thighs, etc.) for possible grafts and/or flaps. Local tissue, compared with skin grafts, is preferable for joint resurfacing after contracture release, as it is more resistant to recurrent contracture. Compliance with splinting and postoperative physiotherapy is paramount in preventing recurrent burn scar contracture.
CLINICAL PROBLEM According to the World Health Organization, burns account for an estimated 265,000 deaths every year, the majority of which occur in low- and middle-income countries.1 Those who survive the acute burn injury often suffer significant lifelong morbidity. Burn patients living in remote villages do not have easy access to health care, let alone the specialized resources necessary to acutely treat a burn. Without early burn excision and skin grafting, splinting, and physiotherapy, burn scar contracture is inevitable for patients with deep partial-thickness and full-thickness burns. Although the ultimate solution for preventing burn scar contracture is to eradicate all burns, this is not today’s reality. Flame burns occur commonly because people of all ages are exposed to open flames for cooking, warmth in the home, and prayer. Whereas women and children are more likely to sustain flame or scald burns related to cooking in the home, men are more likely to sustain flame, scald, electrical, or chemical burns in the workplace. Most cases of post-burn scar contracture present years to decades after the original burn injury. It is common to see teenage patients with burn scar contracture, possibly reflecting the high incidence of burn injuries sustained by children at home; the teenagers are now of working age and desire a functional limb. The patient will present with a gross deformity and limited range of motion about the affected joint. Epilepsy can be associated with post-burn scar contracture because patients can fall into flames and/or scalding liquids during a seizure. More commonly associated conditions include malnutrition and anemia.
PRE-OPERATIVE MANAGEMENT The physical examination is the most critical component of the preoperative management of a patient with post-burn contracture of the
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elbow or wrist. The elbow is most commonly contracted in a flexed position, whereas the wrist can be contracted in either a flexed or an extended position. Dorsal hand/wrist burns cause contracture of the wrist in hyperextension, whereas volar hand/wrist burns cause contracture of the wrist in flexion. Examine the involved joint, identify scar bands, assess range of motion, and document the degree of flexion or extension contracture. Inspect the quality of the soft tissue surrounding the scar bands causing joint contracture to determine whether local tissue can be used for resurfacing the joint after contracture release. Also assess the patient’s groin, thighs, back, chest, and abdomen, because these areas may be necessary donor sites for skin grafts and/or flaps. Examine joints proximal and distal to the involved joint because patients with elbow joint contracture can have concomitant axillary and wrist contractures, and digit contractures commonly occur with wrist contractures. Pre-operative testing needs are minimal for patients undergoing post-burn contracture release. A plain radiograph, if available, to assess the integrity of the affected joint can help the surgeon plan appropriately for surgery. The presence of growth abnormalities from prolonged joint contracture, heterotopic ossification, and so on, can result in marked range-of-motion restrictions that will not be corrected by soft tissue scar release alone. A hemoglobin concentration can be useful if an extensive surgery is planned due to the prevalence of associated anemia in low- and middle-income countries. The upcoming surgery can also be used as a time to screen patients for blood-borne infectious disease such as hepatitis B, hepatitis C, and HIV/AIDS because many people do not have routine access to health care/screenings. Surgery should not be delayed in children because prolonged joint contracture can restrict growth of the joint and surrounding long bones, causing significant functional impairment. Additionally, the social stigmata of burn scar contracture can have a lifelong psychological impact on young patients. If no other more pressing medical or surgical issues exist, release of the joint near the time of presentation can help the patient to develop more normally and to reintegrate into society in a timely fashion. Supplies necessary for surgery include surgical instruments, suture, soft dressings, and splinting materials. Only 5 surgical instruments are critical for this case: a scalpel with #10 or #15 surgical blade, a forceps (preferably Adson), skin hooks (single or double), dissecting scissors (Littler or tenotomy), and a needle holder. A monopolar or bipolar electrosurgery unit is necessary to achieve hemostasis. If one of these units is not available, a handheld electrocautery device can be used instead. A tourniquet, if available, can be helpful for extremity surgery because it facilitates safe dissection by creating a bloodless field, and minimizes overall blood loss during the operation. A dermatome is useful if the case requires a split-thickness skin graft, but it is not absolutely necessary because a graft can be harvested with a handheld knife.
CHAPTER 4.7 Elbow and Wrist Burn Reconstruction When choosing suture, use what is available. 3-0 or 4-0 absorbable suture can be used to secure deep tissue, and 3-0 or 4-0 chromic gut or plain gut can be used for the skin. Preferentially use absorbable sutures (chromic gut or plain gut) instead of permanent sutures (nylon or silk) when performing elbow/wrist burn scar contracture release in children to avoid the fear and perceived/real pain associated with suture removal in children. Dressings should include emollient gauze and 4×4s. The splint is arguably the most important part of the operation because failure to splint the patient in the appropriate post-operative position can lead to early recurrence of joint contracture. To fashion a proper splint, the surgeon will need plaster or fiberglass splint material and cotton cast padding. It is critical to use some form of cast padding to prevent pressure wounds from an ill-fitting splint. The choice of general anesthesia versus local anesthesia, with or without sedation, is largely determined by the patient’s age and the extent of surgery that is planned. If the patient has a neck contracture, release the neck contracture under local anesthesia before inducing general anesthesia or giving any sedatives. It is extremely difficult to intubate a patient with a neck contracture, so the contracture must be released before intubation.2 A child should be at least 3 months of age to safely undergo general anesthesia. It is reasonable to test a serum alkaline phosphatase level pre-operatively if the patient will undergo general anesthesia and has had general anesthesia in the past because some inhalation anesthetics can have the side effect of elevated serum alkaline phosphatase levels. Several local anesthetics are acceptable for joint contracture release, including lidocaine, with or without epinephrine, and bupivacaine, with or without epinephrine. Bupivacaine is less preferable due to its increased cardiotoxicity compared with lidocaine and its unknown effects in children under the age of 12. Remember the following cumulative safe doses for the aforementioned local anesthetics: Lidocaine (0.5% or 1%) with 1 : 200,000 epinephrine—7 mg/kg Lidocaine (0.5% or 1%) without epinephrine—4 mg/kg
271
FIG. 4.7.1 Ulnar deviation of the wrist and hyperabduction of the ulnarmost digit caused by scar tissue along the dorsoulnar hand and wrist— dorsal view.
SURGERY During the pre-operative physical examination, prominent scar bands causing elbow or wrist contracture are identified. Additionally, the quality of soft tissue surrounding the joint should be assessed. One should be fully aware of critical structures that may be injured during scar contracture release. At the level of the elbow, there are several critical structures that may be closely adhered to the overlying scar. The brachial artery and median nerve lie just underneath the lacertus fibrosus. The biceps tendon, critical for active elbow flexion, may become the limiting structure preventing further elbow extension. This should not be transected. At the level of the wrist, critical volar structures include the median nerve and radial nerve, which are fairly superficial. The ulnar artery and ulnar nerve lie protected underneath the flexor carpi ulnaris tendon, but they are still at risk in deep burn contractures. The patient in Figs. 4.7.1 and 4.7.2 has a post-burn contracture of the right hand and wrist that is causing ulnar deviation of the wrist and hyperabduction of the ulnar-most digit. The scar band along the ulnar aspect of the wrist and hand is responsible for this contracture. The remaining skin of the dorsal and volar hand and wrist is soft and mobile. This indicates that local tissue rearrangement in the form of several Z-plasties is the preferred method for contracture release and soft tissue coverage. The four fundamental functions of a Z-plasty are to lengthen a scar, to break up a straight line, to move tissues from one area to another, and to obliterate or create a web or cleft (Table 4.7.1).3 Local flaps should be utilized as much as possible because they have a lower incidence of recurrent contracture compared with skin grafts and do not require an additional donor site.4
FIG. 4.7.2 Volar view.
TABLE 4.7.1 The Four Fundamental
Functions of Z-Plasty
1. To lengthen a scar 2. To break up a straight line 3. To move tissues from one area to another 4. To obliterate or create a web or cleft Reproduced from Lorenz P, Bari AS. Scar prevention, treatment, and revision. In: Neligan P, Gurtner GC, eds. Plastic Surgery. 3rd ed, vol 1. London: Elsevier Saunders; 2013.
Z-plasties are designed over the scar band. Think of the scar band as the central portion of the Z-plasty with the limbs of the “Z” placed on either side of this central scar band. When designing Z-plasties, remember that all limb lengths must be equal. A 60-degree angle gives a theoretical gain in scar length of 75% (Table 4.7.2). Several Z-plasties designed in series will help release the contracture by adequately lengthening the scar.
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TABLE 4.7.2 Z-Plasty Gains in Length Angle of Lateral Limb of Z-Plasty 30 45 60 75 90
Theoretical Gain in Length of Central Limb (%) 25 50 75 100 120
Reproduced from Lorenz P, Bari AS. Scar prevention, treatment, and revision. In: Neligan P, Gurtner GC, eds. Plastic Surgery. 3rd ed, vol 1. London: Elsevier Saunders; 2013.
Local anesthesia is injected in the areas of planned incision. A tourniquet, if available, is applied to the forearm or upper arm for wrist contracture release. The patient will better tolerate the tourniquet on the forearm compared with the upper arm for wrist surgery if he or she is awake, and the arm is not blocked with a regional anesthetic. Cases of elbow contracture release will require placement of the tourniquet on the upper arm. The tourniquet is inflated to 100 mm Hg above the patient’s systolic blood pressure to help prevent excessive pressure on the arm, which can lead to neuropraxia. The skin along the planned markings is incised using a #10 or #15 surgical blade. Each flap is elevated off of underlying muscles and tendons (Fig. 4.7.3). Each flap should contain skin and subcutaneous tissue and should be left thick to improve the vascularity, and ultimate viability, of the flap. Single or double skin hooks can be used for retraction. Flap elevation can be performed with a scalpel or dissecting scissors. Most critical neurovascular structures are deep to the plane of dissection. In this case the ulnar artery and nerve will be protected beneath forearm muscles/tendons; however, one must watch for the dorsal sensory branch of the ulnar nerve during dissection. Depending on the location of the wrist or elbow contracture, other commonly encountered cutaneous nerves include the palmar cutaneous branch of the median nerve, the dorsal sensory branch of the radial nerve, the lateral antebrachial cutaneous nerve, and the medial antebrachial cutaneous nerve. The position of the wrist and digits is evaluated to ensure that the contracture has been adequately released before insetting the flaps. In this case, dorsal and volar views of the hand and wrist demonstrate that the wrist is now neutral in the radial-ulnar plane and that the ulnar-most digit is no longer hyperabducted (Figs. 4.7.4 and 4.7.5). Kirschner wires (K-wires) can be used as internal splints for digits if available. Splinting of the proximal interphalangeal joint is avoided, if possible, to prevent stiffness of the digit. Hemostasis is achieved with a monopolar or bipolar electrosurgery unit or handheld electrocautery device. Adjacent triangular flaps are rearranged. The flaps must be transposed to achieve the desired lengthening effect (Fig. 4.7.6). The flaps are secured in the correct orientation using a few interrupted, buried, deep-dermal 3-0 or 4-0 sutures. The skin is closed with 3-0 or 4-0 chromic gut or plain gut simple or mattress, interrupted sutures. Figs. 4.7.7, 4.7.8, and 4.7.9 demonstrate the patient’s hand with healthy soft tissue across the wrist and ulnar-most metacarpophalangeal joint after local tissue rearrangement. If a soft tissue deficit exists after insetting the flaps, a full-thickness skin graft can be harvested from the groin, lower abdomen, or antecubital fossa. The graft should be sufficiently defatted to enhance its “take.” Raw surfaces are covered with the full-thickness skin graft and sutured in place using 3-0 or 4-0 chromic gut or plain gut suture. If a large soft tissue deficit exists after flap inset, a split-thickness skin graft may be harvested from the anterior thigh or any other available donor site. The
FIG. 4.7.3 Flap elevation off of the underlying muscles and tendons.
FIG. 4.7.4 Correction of contracture after scar release. Note the use of K-wire for internal splinting—dorsal view.
FIG. 4.7.5 Volar view.
CHAPTER 4.7 Elbow and Wrist Burn Reconstruction
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Tension
60°
FIG. 4.7.7 Healthy soft tissue surrounding the original burn scar allows for wound closure via Z-plasties.
75% gain in length
FIG. 4.7.8 Volar view.
FIG. 4.7.6 Z-plasty technique. (Reproduced from Lorenz P, Bari AS. Scar prevention, treatment, and revision. In: Neligan P, Gurtner GC, eds. Plastic Surgery. 3rd ed, vol 1. London: Elsevier Saunders; 2013.)
FIG. 4.7.9 Ulnar view.
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dermatome is usually set to 0.012 to 0.016 inch. The split-thickness skin graft can be used as a sheet graft. Meshed split-thickness skin grafts are avoided, if possible, because their interstices heal by secondary intention and can cause recurrent contracture. Accumulation of hematoma and/or seroma under a skin graft will impede its ability to survive. Quilting sutures throughout the graft can improve graft survival by decreasing the dead space between the graft and the wound bed. Additionally, tie-over bolster dressings improve the surface contact between the graft and wound bed by applying constant pressure to the graft.
POST-OPERATIVE CARE The bolster component of the “tie-over bolster dressing” can be created by wrapping a ball of cotton moistened by mineral oil in a piece Xeroform or other emollient gauze. The bolster should be large enough to cover the entire skin graft, and is normally secured to the skin surrounding the skin graft using 4-0 nylon or silk suture. The remaining incisions should be covered with Xeroform or another form of emollient gauze. After release of wrist contractures, the hand is splinted in the intrinsicplus position, with the wrist in 30 degrees of extension. If a contracture release of the dorsal wrist is performed, it is acceptable to splint the wrist in a more neutral position (less than 30 degrees of wrist extension) to help prevent recurrent contracture of the wrist. Elbow flexion contractures should be splinted in full extension post-operatively.5 Antibiotics that cover skin flora for 1 week post-operatively may be given prophylactically to help prevent surgical site infection. The splint that was applied immediately after surgery should be worn 24 hours a day by the patient and is normally removed on post-operative day 5. The splint should be removed immediately and all surgical sites evaluated if the patient develops a fever or erythema of the upper extremity. If a skin graft was not used, no further dressings are needed after splint removal, and the incision lines can be left open to air. If a skin graft was used, the tie-over bolsters are removed on post-operative day 5. The grafts are then cleaned with normal saline daily, and a small amount of bacitracin ointment is applied daily until all wounds have healed. Steri-Strips or suture strips can be used, if available, to reinforce the skin closure at the fullthickness skin graft donor site until the Steri- or suture strips fall off. A hand therapist should see the patient on post-operative day 5 at the time of the first dressing change. Fabrication of an orthoplast splint at this time will help facilitate daily dressing changes. Range-of-motion exercises and use of the affected extremity for activities of daily living can begin at 2 weeks post-operatively if skin grafts are stable and the incisions are healing well. The patient should be instructed to wear the removable splint 24 hours a day, 7 days a week, for 2 to 3 months, removing it only to change dressings and to work on therapy exercises. The hand therapist can also help educate family members on the importance of splint compliance, and on the safe application and removal of the splint. After 2 to 3 months, the hand therapist will determine whether it is appropriate for the patient to transition to nighttime-only splint use. Return to work should be determined on a caseby-case basis because this decision depends on a multitude of factors.
MANAGEMENT OF COMPLICATIONS The most common complication of burn scar contracture release is recurrence of contracture.6 The patient will present with decreased range of motion at the site of previous contracture release and with a visible scar band that limits range of motion. To address the recurrent contracture, the wrist (or elbow) contracture is re-released and a different surgical option for soft tissue coverage is planned. Often, recurrent contracture occurs because of patient noncompliance with post-operative splinting protocols. To prevent recurrent contracture from lack of
FIG. 4.7.10 Soft tissue is preserved directly over the dorsal wrist joint.
FIG. 4.7.11 The remaining large soft tissue defect is covered with a split-thickness sheet graft.
splinting, patient compliance with splinting and physiotherapy protocols must be ensured before embarking on another operation. Using a split-thickness skin graft for recurrent contractures can be considered if the soft tissue defect is large and a split-thickness skin graft was not previously used. If possible, the patient’s native soft tissue is left directly over the joint because it is more resistant to contracture than the skin graft (Figs. 4.7.10 and 4.7.11). Suture lines directly over joints are avoided because they can promote contracture. In severe cases of dorsal wrist/hand contracture, the extensor tendons may require tenotomy (stair-step) for lengthening or even complete transection. The retrograde posterior interosseous artery (PIA) flap can transfer supple soft tissue from the dorsal forearm to open wounds of the dorsal or volar wrist when recurrent contracture occurs because Z-plasties and skin grafts have failed. The flap is based distally on the PIA, which is located between the extensor digiti minimi (EDM) in the 5th extensor compartment and the extensor carpi ulnaris (ECU) in the 6th extensor compartment.7 The retrograde perfusion of this flap is dependent on the distal communication between the anterior interosseous artery (AIA) and the PIA just proximal to the distal radioulnar joint (DRUJ). This connection is absent in approximately 5% of people, so it is important to explore the pedicle before full flap elevation.
CHAPTER 4.7 Elbow and Wrist Burn Reconstruction
A
B
275
C
FIG. 4.7.12 (A) Incision planning for a posterior interosseous artery (PIA) flap. (B) Elevation of the PIA flap and closure of a larger fasciocutaneous donor site with a split-thickness skin graft. (C) Rotation of the PIA flap to reconstruct a moderate-size ulnar palmar defect. (Reprinted from Page R, Chang J. Reconstruction of hand soft-tissue defects: alternatives to the radial forearm fasciocutaneous flap. J Hand Surg Am. 2006;31A(5):847-855.)
The axis of the flap is along a line joining the lateral epicondyle of the elbow and the DRUJ. A perforator of the PIA, located at the midpoint of this axis, should be included in the flap design. The reliable proximal limit of the flap is 6 cm distal to the lateral epicondyle. The pivot point is 2 cm proximal to the DRUJ (Fig. 4.7.12). Flap elevation should begin with exploration of the pedicle through a curvilinear incision, along the axis of the flap, located between the pivot and the planned distal border of the flap. The PIA will be located on the interosseous membrane at the base of the septum between the EDM and ECU tendons. If the distal PIA is absent and the distal communication with the AIA is absent, the procedure is discontinued. The ulnar border of the flap is incised, and the flap is elevated subfascially toward the septum. The radial border is elevated next. With the tourniquet deflated, an atraumatic clamp is applied to the proximal pedicle to assess distal perfusion to the flap before dividing the proximal pedicle. The flap can be used to cover defects of the dorsal or volar wrist. In cases of recurrent post-burn contracture of the elbow, a distally based lateral arm flap can be used to resurface the volar elbow joint.8 Although the distally based PIA flap and the distally based lateral arm flap are ideal axial flaps for wrist and elbow contracture, respectively, less complex flaps can be used to bring healthy tissue over a joint. The pedicled groin flap can be used for the wrist, and a random-pattern skin/subcutaneous tissue flap from the trunk can be used for the elbow. These flaps are reliable and easy to harvest; however, they require patient compliance during neovascularization of the flap (the patient is tethered to the groin or chest for 3 weeks before flap division and inset) and during post-operative physiotherapy for joint stiffness.
KEY REFERENCES 1. World Health Organization. Burns fact sheet. http://www.who.int/ mediacentre/factsheets/fs365/en/. Accessed January 12, 2017.
KEY PRINCIPLES • Never create a longitudinal (straight line) incision across the flexor surface of a joint. The resultant scar will cause joint contracture. • Utilize local flaps as much as possible to resurface raw surfaces after joint contracture release. • Avoid use of split-thickness skin grafts over joints if possible. Full-thickness skin grafts have less secondary contracture than split-thickness grafts and leave a better donor site scar. • Use quilting sutures and bolster dressings to help prevent hematoma/seroma under skin grafts. • Splint post-operatively to prevent recurrent joint contracture.
2. Kreulen M, Mackie DP, Kreis RW, et al. Surgical release for intubation purposes in postburn contractures of the neck. Burns. 1996;22(4):310–312. 3. Lorenz P, Bari AS. Scar prevention, treatment, and revision. In: Neligan PC, Gurtner GC, eds. Plastic Surgery. vol. I. 3rd ed. St. Louis, MO: Saunders Elsevier; 2005:297–318. 4. Schwarz RJ. Management of postburn contractures of the upper extremity. J Burn Care Res. 2007;28(2):212–219. 5. Borghese L, Masellis A, Masellis M. Extremity burn reconstruction. In: Neligan PC, Chang J, eds. Plastic Surgery. vol. VI. 3rd ed. St. Louis, MO: Saunders Elsevier; 2005:435–455. 6. Balumuka DD, Galiwango GW, Alenyo R. Recurrence of post burn contractures of the elbow and shoulder joints: experience from a Ugandan hospital. BMC Surg. 2015;15:103. 7. Page R, Chang J. Reconstruction of hand soft-tissue defects: alternatives to the radial forearm fasciocutaneous flap. J Hand Surg Am. 2006;31A(5):847–855. 8. Turegun M, Nisanci M, Duman H, et al. Versatility of the reverse lateral arm flap in the treatment of post-burn antecubital contractures. Burns. 2005;31:212–216.