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Postburn volar digital contractures in nigerians
Postburn Volar Digital Contractures in Nigerians Lawrence M. lregbulem
POSTBURN V O L A R D I G I T A L C O N T R A C T U R E S IN N I G E R I A N S L A W R E N C E M. I R E G B U L E M , Enugu, Nigeria
SUMMARY In fifty-six Nigerian children, 178 digits with volar contractures have been treated by skin grafts and flaps during the past three years. The severity of contracture was graded and corrective treatment planned accordingly. Patients have been reviewed from three months to three years after correction. The results have been better than expected using Wolfe grafts rather than split skin for the majority, and direct flaps only when imperative. INTRODUCTION Burns of the upper extremities are common in Nigeria, where about 80% of the population live in the rural areas. Domestic cooking is done almost exclusively on open fires and few people take even simple precautions against fire burn injuries. The victims are usually young children who traditionally are encouraged to crawl at an early age and the glow of an open fire is a constant source of fascination to children, who are often left unattended or in the care of older children; they explore these fires with their hands. The most unfortunate aspect of hand burns is the total lack of specialised care at an early stage. Parents' quest for treatment is directed firstly to the traditional 'medicine man' then to the patent medicine dealer and lastly to a local health centre. Many weeks elapse before the child reaches a general hospital, and it may be months or years before referral to a Plastic or other specialist Unit. Hence, a superficial burn is converted into a deep burn by gross secondary infection. Healing is slow and protracted with resultant contractures mainly from skin shortage, shortening of tendon sheaths and collateral ligaments, and volar plate adhesions (Jackson, 1975). TYPES OF PATIENTS Within a few weeks of establishing the Plastic Unit of the National Orthopaedic Hospital in Enugu, it became clear to me that a large percentage of the ' h a n d ' work in the unit would consist of releasing postburn contractures. Of 152 patients who were seen, (in the three years between January 1975 and January 1978) with postburn contractures of various parts of the body, fifty-six had volar contractures involving the digits. A plan of management for these was therefore formulated. The contractures were graded into four groups according to the severity, that is the extent of digital flexion with the hand at rest. Each digit was considered separately. The grading was as follows:Group I (mild) Fixed flexion at the I.P. joints of less than 90 ~ (Fig. 1). Group II (Moderate) The degree of flexion was 90 ~ or over, but the digit was not in contact with the palm (Fig. 2). Group III (Severe) In this group, all three joints (metacarpophalangeal, proximal interphalangeal and distal interphalangeal) were flexed to their limits, so Lawrence M. Iregbulem, F.R.C.S., F.R.C.S.(E)., National Orthopaedic & Plastic Hospital, P.M.B. 1294, Enugu, Nigeria 9 1980British Societyfor Surgeryof the Hand 0072-968X-80-00080054 $02.00 54
The H a n d - - Volume 12
No. 1
1980
Postburn Volar Digital Contractures in Nigerians Lawrence M. lregbulem
Fig. 1. Group I (Mild) Vol~r contracture of index finger. I.P. joint flexion less than 90~ Fig. 2. Group II (Moderate) Volar contracture of index finger. 1.P. joint flexion 90~ or over. No contact with palm. that the pulp o f the digit was touching the palm (Fig. 3). Usually, several digits were involved and secondary syndactyly was present. G r o u p IV (Complicated) This group included all patients in which there was digital mutilation with loss o f whole parts o f the digits. (Fig. 4). Involvement o f all the digits was the rule although even in these patients the t h u m b tended to be affected to a lesser extent. Webbing o f contiguous digits was also the rule. One hundred and seventy eight digits were affected by postburn volar contracture in these fifty six children (see Table 1 and 2 for distribution). TABLE 1 GRADES OF SEVERITY
MILD Group I
MODERATE G r o u p II
SEVERE Group III
COMPLICATED G r o u p IV
TOTAL
34
102
32
10
178
The H a n d - - Volume 12
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1980
55
Postburn Volar Digital Contractures in Nigerians Lawrence M. lregbulem
Fig. 3. Group III (Severe)Volar contractures in all fingers.
In twenty eight patients, the right hand only was involved, and in twenty two patients, the left. Both hands were affected in six patients. There were thirty two males against twenty four females. Although most of the patients (forty eight) were below the age of twelve years, the youngest was one year old. The interval between the time of injury and presentation at the Plastic Surgery Clinic varied, but the median interval was twelve months. On analysis o f the various causes of the burn injury, it was found that " o p e n fires" accounted for nearly one-half of the cases. Other factors were hot objects, inflammable liquids and chemicals (Table 3).
TABLE 2
INVOLVEMENT OF INDIVIDUAL DIGITS
56
THUMB
INDEX
MIDDLE
RING
LITTLE
TOTAL
4
34
52
46
42
178
The H a n d - - Volume 12
No. 1
1980
Postburn Volar Digital Contractures in Nigerians Lawrence M. Iregbulem
Fig. 4. Group IV (Complicatedj Volar contraCtures in all fingers. Note loss of terminal phalanges in index and middle fingers. Fig. 5. Postoperativeresult after surgeryin patient in Fig. 4. Management The object of surgical operation was to obtain the best result with the least complicated procedure in the minimal time. Under general anaesthesia and a tourniquet, wide and complete excision of all scar tissue (i.e. skin, subcutaneous scar TABLE 3 AETIOLOGICAL FACTORS IN HAND BURNS
O P E N FIRES
24
HOT LIQUIDS (WATER/FAT)
14
H O T OBJECTS ( C H A R C O A L , SAND, METAL)
12
INFLAMMABLE LIQUIDS (PARAFFIN, PETROL)
4
CHEMICALS
2
ELECTRICAL
0
The Hand--Volume 12
No. 1
1980
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Postburn Volar Digital Contractures in Nigerians Lawrence M. Iregbulem
Fig. 6. Result after release and Wolfe graft to index and middle fingers. Note absence of marginal keloid. Colour disparity still obvious at one year. a n d occasionally the t e n d o n sheath) was carried out. T h e digital n e u r o v a s c u l a r b u n d l e s were identified r o u t i n e l y at the level o f the j u n c t i o n of the dorsal a n d p a l m a r skin o n each side a n d preserved as was as m u c h s u b c u t a n e o u s fat as possible. I n G r o u p s I a n d II, W o l f e grafts were used for skin cover. As most o f these patients were children, the size o f the defects following excision surgery was u n i m p o r t a n t . Excellent graft " t a k e " was usual.
TABLE 4 DEGREES OF LOSS OF ACTIVE EXTENSION IN DIGITS AFTER SURGERY. (NUMBER OF DIGITS IN BRACKETS) RESULTS
MILD Group I (28)
MODERATE Group II (90)
SEVERE Group IIl (30)
COMPLICATED Group IV (10)
VERY GOOD (0~ ~
(28) 100o7o
(90) 100o70
--
--
GOOD (11 ~176
--
--
(20) 66.6%
(4) 40%
--
--
(10) 33.3~
(6) 60%
FAIR (210-30 ~ 58
The H a n d - - Volume 12
No. 1
1980
Postburn Volar Digital Contractures in Nigerians Lawrence M. Iregbulem
In a few adults, however, the size o f the defect restricted the use of Wolfe grafts and thick split skin grafts (half-skin thickness) were used. Digital stabilisation was accomplished by the use of Kirschner wires, although in some cases plaster o f Paris slabs were used for speed and economy. All grafts were inspected on the seventh postoperative day when the first change of dressing was made. The wires were removed at three weeks. Physiotherapy was commenced thereafter and continued for a period of six to eight weeks on an out-patient basis where possible. The donor area o f choice in Wolfe grafts was the groin crease laterally, well away from the hair-bearing area, the defect being closed primarily with minimal undermining. Where multiple digits were involved, two adjacent digits were dealt with at one sitting. Secondary syndactyly was corrected by a combination o f local flaps and skin grafts to denuded areas. For Groups III and IV types of volar contractures, the neurovascular bundles and flexor tendons (which were often tented), as well as the collateral ligaments and the joints were exposed. The tendon sheaths were excised as they were invariably grossly shortened. The volar plate when adherent to the phalanx, was freed by blunt dissection. Any residual contracture at this stage is likely to be due to the shortened collateral ligaments and should respond ,to gentle and sustained stretching but the neurovascular bundles are liable to damage if over-stressed, The corrected position of the digit was then maintained by Kirschner wire fixation. Apart f r o m the nature of the tissues exposed in these groups, the resultant defects are often large. Skin coverage must of necessity, be by distant flaps. The groin flap was found to be extremely versatile and safe, and amenable to comfortable postoperative immobilisation in children, and was therefore used in all cases. The main disadvantage of flaps, however, is their bulk which usually requires reduction by defattening at a subsequent operation six months later. RESULTS
One hundred and fifty eight digits were assessed at follow-up over a period ranging from three months to three years, with an average of one year. The assessment was made on the basis of (a) function (i.e. everyday use, range of finger movements, and sensation) and (b) general appearance and colour match of the added skin. Parents were questioned closely about their childrens' ability to use the digit or digits in everyday activities. O f forty eight parents interviewed, forty six had not observed any significant limitation of use in the involved digits. Finger movements were graded according to the degree of residual loss of active extension as follows:0 ~ - - 10 ~ : Very good 11 ~ - - 20 ~ : G o o d 21 ~ - - 30 ~ : Fair Over 30 ~ : Poor Details of the assessed finger movements using the above criteria are shown in Table IV from which it can be seen that very satisfactory results were obtained in all The H a n d - - Volume 12
No. 1
1980
59
Postburn Volar Digital Contractures in Nigerians Lawrence M. Iregbulem
cases of Groups I and II. In Groups III and IV, the results ranged from " g o o d " to " f a i r " , but no " p o o r " results were recorded. Tests for sensation were limited to pin-prick and light touch. There was no loss or diminution in these for older children in whom reliable response could be elicited. The general appearance was markedly improved in all the digits treated. Due to the relative lack of pigmentation in the volar skin of the negro, an acceptable colour match was never obtained in the very dark children. However, in children of lighter colour, the disparity between the transplanted groin skin and the recipient volar skin was less noticeable, and an agreeable colour match was achieved in most. DISCUSSION Rural Nigeria is an agrarian society where manual labour is essential for survival. Surgical correction for the restoration of manual function is thus extremely important. Burns in children show a particular tendency to hypertrophic scarring which is also true in Nigeria. An important aspect of burn contracture emphasised by Buchan (1971), but still not widely recognised, is that these contractures are produced not only by skin loss but also by the differential growth rates between the burn scar and the rest of the hand. Consequently a child m a y continue to develop skin contracture years after the initial injury. These factors combine to present the surgeon in Nigeria with gross and incapacitating burn contractures. In spite of this, my policy in the release of these lesions (based on the well tried surgical principle of adequate excision of all scar tissue in a bloodless field using a tourniquet, appropriate immobilisation, release of the tourniquet and meticulous haemostasis, and then application of skin coverage) has yielded successful results (Fig. 5). Like other workers (Rank 1960; Finseth 1975) Wolfe grafts were found to give the best functional results. In over 136 consecutive cases, not a single Wolfe graft was lost. Although thick split skin grafts were used in adults to cover large defects, there does not appear to be any place for the use of thin split skin grafts in the replacement of volar skin in any age group as the risk of recurrent contracture is common. When deep structures such as nerves, tendons and joints are exposed, coverage by a distant flap becomes the method of choice. Here again, in over sixteen groin flaps, not a single case of necrosis, partial or total, was recorded. There were slightly more male than female children in this series, which is not surprising because male children appear to be more adventurous. The right and left hands were equally involved which is in keeping with the observation that most children are still ambidextrous at the age of two years. As regards the aetiological factors in burn injury nearly all the various causes were directly related to the local socio-economic environment, (open fires, hot charcoal etc.) whereas only about 10% were associated with urban life (petrol, chemicals etc). One surprising finding in this study was the low incidence of keloid scar at the edges of the transplanted skin which is so frequently seen in other parts of the body (Fig. 6). In 136 Wolfe grafts, only one instance of marginal keloid was noted at follow-up. This agrees with Calnan's estimate (1963) of 1% at this site. Growth of 60
The H a n d - - Volume 12
No. 1
1980
Postburn Volar Digital Contractures in Nigerians Lawrence M. Iregbulem
the transplanted skin however, appeared to be normal. N o matter how successful the treatment o f such burn contractures, it must be borne in mind that "the burned hand o f a child may become contracted and deformed despite the excellence of both medical and surgical care". (Smith, 1966). Clearly our future goal should be prevention. REFERENCES B U C H A N , A. C. (1971) Deep Burns - - Burn Contractures. The Hand. 3: 90-96. C A L N A N , J. Keloid., In Recent Advances in Surgery of T r a u m a (Ed. D. N. Matthews) London Churchill. 1963 FINSETH, F., (1975) Plastic Surgery In Rural Ethiopia. Plastic and Reconstructive Surgery 55: 545-550. RANK, B. K. and W A K E F I E L D , A. R. Surgery Of Repair As Applied To Hand Injuries. 2nd Edition. Chapter VI P93. Edinburgh and London, E. & S. Livingstone Ltd. 1960. JACKSON, I. T. and BROWN, G. E. D. (1970) A Method Of Treating Chronic Flexion Contractures Of The Fingers. British Journal of Plastic Surgery 23: 373-379. SMITH, J. W., (1966) Burned H a n d s in Children, The American Journal of Surgery 112; 58-64.
The H a n d - - Volume 12
No. 1
1980
61
POSTBURN V O L A R D I G I T A L C O N T R A C T U R E S IN N I G E R I A N S L A W R E N C E M. I R E G B U L E M , Enugu, Nigeria
SUMMARY In fifty-six Nigerian children, 178 digits with volar contractures have been treated by skin grafts and flaps during the past three years. The severity of contracture was graded and corrective treatment planned accordingly. Patients have been reviewed from three months to three years after correction. The results have been better than expected using Wolfe grafts rather than split skin for the majority, and direct flaps only when imperative. INTRODUCTION Burns of the upper extremities are common in Nigeria, where about 80% of the population live in the rural areas. Domestic cooking is done almost exclusively on open fires and few people take even simple precautions against fire burn injuries. The victims are usually young children who traditionally are encouraged to crawl at an early age and the glow of an open fire is a constant source of fascination to children, who are often left unattended or in the care of older children; they explore these fires with their hands. The most unfortunate aspect of hand burns is the total lack of specialised care at an early stage. Parents' quest for treatment is directed firstly to the traditional 'medicine man' then to the patent medicine dealer and lastly to a local health centre. Many weeks elapse before the child reaches a general hospital, and it may be months or years before referral to a Plastic or other specialist Unit. Hence, a superficial burn is converted into a deep burn by gross secondary infection. Healing is slow and protracted with resultant contractures mainly from skin shortage, shortening of tendon sheaths and collateral ligaments, and volar plate adhesions (Jackson, 1975). TYPES OF PATIENTS Within a few weeks of establishing the Plastic Unit of the National Orthopaedic Hospital in Enugu, it became clear to me that a large percentage of the ' h a n d ' work in the unit would consist of releasing postburn contractures. Of 152 patients who were seen, (in the three years between January 1975 and January 1978) with postburn contractures of various parts of the body, fifty-six had volar contractures involving the digits. A plan of management for these was therefore formulated. The contractures were graded into four groups according to the severity, that is the extent of digital flexion with the hand at rest. Each digit was considered separately. The grading was as follows:Group I (mild) Fixed flexion at the I.P. joints of less than 90 ~ (Fig. 1). Group II (Moderate) The degree of flexion was 90 ~ or over, but the digit was not in contact with the palm (Fig. 2). Group III (Severe) In this group, all three joints (metacarpophalangeal, proximal interphalangeal and distal interphalangeal) were flexed to their limits, so Lawrence M. Iregbulem, F.R.C.S., F.R.C.S.(E)., National Orthopaedic & Plastic Hospital, P.M.B. 1294, Enugu, Nigeria 9 1980British Societyfor Surgeryof the Hand 0072-968X-80-00080054 $02.00 54
The H a n d - - Volume 12
No. 1
1980
Postburn Volar Digital Contractures in Nigerians Lawrence M. lregbulem
Fig. 1. Group I (Mild) Vol~r contracture of index finger. I.P. joint flexion less than 90~ Fig. 2. Group II (Moderate) Volar contracture of index finger. 1.P. joint flexion 90~ or over. No contact with palm. that the pulp o f the digit was touching the palm (Fig. 3). Usually, several digits were involved and secondary syndactyly was present. G r o u p IV (Complicated) This group included all patients in which there was digital mutilation with loss o f whole parts o f the digits. (Fig. 4). Involvement o f all the digits was the rule although even in these patients the t h u m b tended to be affected to a lesser extent. Webbing o f contiguous digits was also the rule. One hundred and seventy eight digits were affected by postburn volar contracture in these fifty six children (see Table 1 and 2 for distribution). TABLE 1 GRADES OF SEVERITY
MILD Group I
MODERATE G r o u p II
SEVERE Group III
COMPLICATED G r o u p IV
TOTAL
34
102
32
10
178
The H a n d - - Volume 12
No. 1
1980
55
Postburn Volar Digital Contractures in Nigerians Lawrence M. lregbulem
Fig. 3. Group III (Severe)Volar contractures in all fingers.
In twenty eight patients, the right hand only was involved, and in twenty two patients, the left. Both hands were affected in six patients. There were thirty two males against twenty four females. Although most of the patients (forty eight) were below the age of twelve years, the youngest was one year old. The interval between the time of injury and presentation at the Plastic Surgery Clinic varied, but the median interval was twelve months. On analysis o f the various causes of the burn injury, it was found that " o p e n fires" accounted for nearly one-half of the cases. Other factors were hot objects, inflammable liquids and chemicals (Table 3).
TABLE 2
INVOLVEMENT OF INDIVIDUAL DIGITS
56
THUMB
INDEX
MIDDLE
RING
LITTLE
TOTAL
4
34
52
46
42
178
The H a n d - - Volume 12
No. 1
1980
Postburn Volar Digital Contractures in Nigerians Lawrence M. Iregbulem
Fig. 4. Group IV (Complicatedj Volar contraCtures in all fingers. Note loss of terminal phalanges in index and middle fingers. Fig. 5. Postoperativeresult after surgeryin patient in Fig. 4. Management The object of surgical operation was to obtain the best result with the least complicated procedure in the minimal time. Under general anaesthesia and a tourniquet, wide and complete excision of all scar tissue (i.e. skin, subcutaneous scar TABLE 3 AETIOLOGICAL FACTORS IN HAND BURNS
O P E N FIRES
24
HOT LIQUIDS (WATER/FAT)
14
H O T OBJECTS ( C H A R C O A L , SAND, METAL)
12
INFLAMMABLE LIQUIDS (PARAFFIN, PETROL)
4
CHEMICALS
2
ELECTRICAL
0
The Hand--Volume 12
No. 1
1980
57
Postburn Volar Digital Contractures in Nigerians Lawrence M. Iregbulem
Fig. 6. Result after release and Wolfe graft to index and middle fingers. Note absence of marginal keloid. Colour disparity still obvious at one year. a n d occasionally the t e n d o n sheath) was carried out. T h e digital n e u r o v a s c u l a r b u n d l e s were identified r o u t i n e l y at the level o f the j u n c t i o n of the dorsal a n d p a l m a r skin o n each side a n d preserved as was as m u c h s u b c u t a n e o u s fat as possible. I n G r o u p s I a n d II, W o l f e grafts were used for skin cover. As most o f these patients were children, the size o f the defects following excision surgery was u n i m p o r t a n t . Excellent graft " t a k e " was usual.
TABLE 4 DEGREES OF LOSS OF ACTIVE EXTENSION IN DIGITS AFTER SURGERY. (NUMBER OF DIGITS IN BRACKETS) RESULTS
MILD Group I (28)
MODERATE Group II (90)
SEVERE Group IIl (30)
COMPLICATED Group IV (10)
VERY GOOD (0~ ~
(28) 100o7o
(90) 100o70
--
--
GOOD (11 ~176
--
--
(20) 66.6%
(4) 40%
--
--
(10) 33.3~
(6) 60%
FAIR (210-30 ~ 58
The H a n d - - Volume 12
No. 1
1980
Postburn Volar Digital Contractures in Nigerians Lawrence M. Iregbulem
In a few adults, however, the size o f the defect restricted the use of Wolfe grafts and thick split skin grafts (half-skin thickness) were used. Digital stabilisation was accomplished by the use of Kirschner wires, although in some cases plaster o f Paris slabs were used for speed and economy. All grafts were inspected on the seventh postoperative day when the first change of dressing was made. The wires were removed at three weeks. Physiotherapy was commenced thereafter and continued for a period of six to eight weeks on an out-patient basis where possible. The donor area o f choice in Wolfe grafts was the groin crease laterally, well away from the hair-bearing area, the defect being closed primarily with minimal undermining. Where multiple digits were involved, two adjacent digits were dealt with at one sitting. Secondary syndactyly was corrected by a combination o f local flaps and skin grafts to denuded areas. For Groups III and IV types of volar contractures, the neurovascular bundles and flexor tendons (which were often tented), as well as the collateral ligaments and the joints were exposed. The tendon sheaths were excised as they were invariably grossly shortened. The volar plate when adherent to the phalanx, was freed by blunt dissection. Any residual contracture at this stage is likely to be due to the shortened collateral ligaments and should respond ,to gentle and sustained stretching but the neurovascular bundles are liable to damage if over-stressed, The corrected position of the digit was then maintained by Kirschner wire fixation. Apart f r o m the nature of the tissues exposed in these groups, the resultant defects are often large. Skin coverage must of necessity, be by distant flaps. The groin flap was found to be extremely versatile and safe, and amenable to comfortable postoperative immobilisation in children, and was therefore used in all cases. The main disadvantage of flaps, however, is their bulk which usually requires reduction by defattening at a subsequent operation six months later. RESULTS
One hundred and fifty eight digits were assessed at follow-up over a period ranging from three months to three years, with an average of one year. The assessment was made on the basis of (a) function (i.e. everyday use, range of finger movements, and sensation) and (b) general appearance and colour match of the added skin. Parents were questioned closely about their childrens' ability to use the digit or digits in everyday activities. O f forty eight parents interviewed, forty six had not observed any significant limitation of use in the involved digits. Finger movements were graded according to the degree of residual loss of active extension as follows:0 ~ - - 10 ~ : Very good 11 ~ - - 20 ~ : G o o d 21 ~ - - 30 ~ : Fair Over 30 ~ : Poor Details of the assessed finger movements using the above criteria are shown in Table IV from which it can be seen that very satisfactory results were obtained in all The H a n d - - Volume 12
No. 1
1980
59
Postburn Volar Digital Contractures in Nigerians Lawrence M. Iregbulem
cases of Groups I and II. In Groups III and IV, the results ranged from " g o o d " to " f a i r " , but no " p o o r " results were recorded. Tests for sensation were limited to pin-prick and light touch. There was no loss or diminution in these for older children in whom reliable response could be elicited. The general appearance was markedly improved in all the digits treated. Due to the relative lack of pigmentation in the volar skin of the negro, an acceptable colour match was never obtained in the very dark children. However, in children of lighter colour, the disparity between the transplanted groin skin and the recipient volar skin was less noticeable, and an agreeable colour match was achieved in most. DISCUSSION Rural Nigeria is an agrarian society where manual labour is essential for survival. Surgical correction for the restoration of manual function is thus extremely important. Burns in children show a particular tendency to hypertrophic scarring which is also true in Nigeria. An important aspect of burn contracture emphasised by Buchan (1971), but still not widely recognised, is that these contractures are produced not only by skin loss but also by the differential growth rates between the burn scar and the rest of the hand. Consequently a child m a y continue to develop skin contracture years after the initial injury. These factors combine to present the surgeon in Nigeria with gross and incapacitating burn contractures. In spite of this, my policy in the release of these lesions (based on the well tried surgical principle of adequate excision of all scar tissue in a bloodless field using a tourniquet, appropriate immobilisation, release of the tourniquet and meticulous haemostasis, and then application of skin coverage) has yielded successful results (Fig. 5). Like other workers (Rank 1960; Finseth 1975) Wolfe grafts were found to give the best functional results. In over 136 consecutive cases, not a single Wolfe graft was lost. Although thick split skin grafts were used in adults to cover large defects, there does not appear to be any place for the use of thin split skin grafts in the replacement of volar skin in any age group as the risk of recurrent contracture is common. When deep structures such as nerves, tendons and joints are exposed, coverage by a distant flap becomes the method of choice. Here again, in over sixteen groin flaps, not a single case of necrosis, partial or total, was recorded. There were slightly more male than female children in this series, which is not surprising because male children appear to be more adventurous. The right and left hands were equally involved which is in keeping with the observation that most children are still ambidextrous at the age of two years. As regards the aetiological factors in burn injury nearly all the various causes were directly related to the local socio-economic environment, (open fires, hot charcoal etc.) whereas only about 10% were associated with urban life (petrol, chemicals etc). One surprising finding in this study was the low incidence of keloid scar at the edges of the transplanted skin which is so frequently seen in other parts of the body (Fig. 6). In 136 Wolfe grafts, only one instance of marginal keloid was noted at follow-up. This agrees with Calnan's estimate (1963) of 1% at this site. Growth of 60
The H a n d - - Volume 12
No. 1
1980
Postburn Volar Digital Contractures in Nigerians Lawrence M. Iregbulem
the transplanted skin however, appeared to be normal. N o matter how successful the treatment o f such burn contractures, it must be borne in mind that "the burned hand o f a child may become contracted and deformed despite the excellence of both medical and surgical care". (Smith, 1966). Clearly our future goal should be prevention. REFERENCES B U C H A N , A. C. (1971) Deep Burns - - Burn Contractures. The Hand. 3: 90-96. C A L N A N , J. Keloid., In Recent Advances in Surgery of T r a u m a (Ed. D. N. Matthews) London Churchill. 1963 FINSETH, F., (1975) Plastic Surgery In Rural Ethiopia. Plastic and Reconstructive Surgery 55: 545-550. RANK, B. K. and W A K E F I E L D , A. R. Surgery Of Repair As Applied To Hand Injuries. 2nd Edition. Chapter VI P93. Edinburgh and London, E. & S. Livingstone Ltd. 1960. JACKSON, I. T. and BROWN, G. E. D. (1970) A Method Of Treating Chronic Flexion Contractures Of The Fingers. British Journal of Plastic Surgery 23: 373-379. SMITH, J. W., (1966) Burned H a n d s in Children, The American Journal of Surgery 112; 58-64.
The H a n d - - Volume 12
No. 1
1980
61