- Email: [email protected]
Serial splintage: Preoperative treatment of upper limb contracture
burns 39 (2013) 1096–1100
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns
Serial splintage: Preoperative treatment of upper limb contracture Vinita Puri a, Nishant Khare a,*, N. Venkateshwaran a, Sumit Bharadwaj b, Sushant Choudhary a, Omkarnath Deshpande a, Rupali Borkar c a
Department of Plastic Surgery, Seth GS Medical College & KEM Hospital, Mumbai 12, India Department of Community Medicine, Chirayu Medical College, Bhopal, India c Department of Occupational Therapy, Seth GS Medical College & KEM Hospital, Mumbai, India b
article info
abstract
Article history:
Introduction: The present study aimed to study the efficacy of preoperative splints in
Accepted 4 January 2013
treatment of upper limb contractures and to evaluate the response of contracture to splints depending on the etiology and the joint involved.
Keywords:
Methods: Ninety joints of 42 patients were studied. Patients age, gender, etiology, duration of
Burn
contracture, contracture site and joint and type of contracture was noted. The range of
Contracture
motion of the involved joint was recorded. Serial static splints made of thermoplastic
Hand
material were applied after customizing them for each patient. The range of motion and
Serial splint
percentage movement was recorded at weekly interval and the splints were modified as per
Contracture angle
need. Time taken to reach a plateau stage was noted. To compare the statistical significance between two groups and more than two groups of continuous variable unpaired t-test and one way ANOVA respectively was applied. We considered differences to be statistically significant when the p value was below 0.05. The strength of relationship between the two continuous variables was analyzed by Pearson correlation analysis. Results: Etiological factors were thermal burns (36.7%), electrical burns (13.3%), post traumatic (35.6%) and post cellulitis (14.4%). Age ranged from 2 to 70 years with a mean of 28.9 13.4 years. Sixty-two patients treated were males (68.9%) and 28 were female (31.1%). The mean range of motion present across all joints before starting the therapy was 54.7 23.6 degrees. The mean improvement in contracture angle obtained by serial splintage was 37.4 28.1 degrees. The mean time taken to achieve plateau was 23.6 3.2 days. Maximum improvement was seen in thermal burn contractures (41.2 30.3 degrees). Least improvement was seen in contractures due to cellulitis (6.5 16.2 degrees). This finding was statistically significant [F(3,86) = 4.25, p = 0.005]. Significant difference was seen in response to therapy based on the joint involved [F(3,86) = 3.36, p = 0.02]. Highest improvement in the range of motion was seen in the metacarpophalangeal joint (49.61 31.3 degrees). Conclusions: The preoperative use of splints may lead to lesser surgical intervention and in selective cases obviate surgery. Thermal burns which are the most common cause of contractures of the upper limb, show the maximum response to preoperative serial splintage. Patient with minor contracture and supple tissues are fully corrected with splints without surgical intervention. In patients undergoing surgical correction, skin graft decreases due to decreased contracture angle. # 2013 Elsevier Ltd and ISBI. All rights reserved.
* Corresponding author. Tel.: +91 9619442855. E-mail address: [email protected] (N. Khare). 0305-4179/$36.00 # 2013 Elsevier Ltd and ISBI. All rights reserved. http://dx.doi.org/10.1016/j.burns.2013.01.010
burns 39 (2013) 1096–1100
1.
Introduction
Burn scar contracture has been defined as ‘‘an impairment caused by replacement of skin with pathologic scar tissue of insufficient extensibility and length resulting in a loss of motion or tissue alignment of an associated joint or anatomic structure. Contractures can affect a skin crease, skin juncture, or margin and may secondarily deform adjacent normal structures. Burn scar contractures are labeled according to the antithesis of movement impeded, resultant tissue deviation, or functional deformity’’ [1]. They result from a combination of possible factors – limb positioning, duration of immobilization and muscle, soft tissue, and bony pathology [2]. Upper limb contractures are seen commonly in our clinical practice. They may be due to a variety of causes like burn, trauma and infection. However, contractures due to burns, thermal and electrical, account for an overwhelming majority of these contractures. Failure to seek medical help, inadequate medical care, and inadequate posthealing care are common causes of burn contractures [3]. There are two key elements in burn contracture prevention, namely splinting of the burned area in its anatomic position and regular exercises through each joint’s full range of motion [4]. The same principles can be reasonably applied to contractures of other etiology. Such effective use of splints and mobilization has been described for prevention of contractures. Development of contracture is an ongoing process and may continue for up to 2 years after sustaining the injury [5]. It can thus be posited that any intervention which prevents the progress of contracture should be effective in doing so within this time frame and similarly some attempts at reversing the contracture can be made during this time. Indications for the use of splints in burn care include joint and skin graft protection, positioning to prevent deformity, and positioning to maintain or increase elongation of scar tissue. The principles behind splinting are well established. However, the utilization of splinting is markedly varied among burn therapists, possibly because of the paucity of objective data regarding both intervention parameters and efficacy of splint use [1]. The present study attempts to study the efficacy of preoperative splints in treatment of upper limb contractures and evaluate the response of contracture to splints depending on the etiology. The study is an attempt to provide sufficient data for evaluation of this technique.
2.
Methods
The study was conducted prospectively from September 2008 to April 2011. Ninety joints of 42 patients were studied. Patients age, sex, etiology, duration of contracture, contracture site and joint and type of contracture was noted. The range of motion of the involved joint was recorded. Serial static splints made of thermoplastic material were applied after customizing them for each patient. The therapy protocol consisted of continuous application of the static splint, scar massage with emollient four times a day for 10 min each, passive stretching exercises twice daily for 20–30 min each. The patients were advised to wear the splint continuously and
1097
remove it only at time of exercise, scar massage and when needed for activities like bathing, etc. The therapy was administered at home by their kins or self. All the patients who reported for treatment had already developed contractures at time of initial visit. Twenty-six of the 42 patients were not treated initially at burn care centers and hence did not receive any advise regarding splintage or other forms of therapy. Sixteen of the 42 patients were non compliant to the initial therapy advise. The range of motion and percentage movement was recorded at weekly interval and the splints were modified as per need. Time taken to reach a plateau stage was noted. The discrete variables were reported in percentage and proportion. Continuous variables were reported as mean SD. To compare the statistical significance between two groups and more than two groups of continuous variable unpaired t-test and one way ANOVA respectively was applied. We considered differences to be statistically significant when the p value was below 0.05. The strength of relationship between the two continuous variable was analyzed by Pearson correlation analysis. The analysis was performed using statistical programme (SPSS Version10.0, SPSS Inc., Chicago, USA).
3.
Results
A total of 90 contractures were included in study. Twenty-six of the 42 patients reported that no initial treatment to prevent contracture was offered to them while 16 of 42 patients were non compliant. All the 26 patients who did not receive any initial advise were treated at primary health centers or by local practitioners with no specific training in burn care. Etiological factors were thermal burns (36.7%), electrical burns (13.3%), post traumatic (35.6%) and post cellulitis (14.4%). Age ranged from 2 to 70 years with a mean of 28.9 13.4 years. Sixty-two patients treated were males (68.9%) and 28 were female (31.1%). The mean range of motion present across all joints before starting the therapy was 54.7 23.6 degrees. The mean improvement in contracture angle obtained by serial splintage was 37.4 28.1 degrees. The mean time taken to achieve plateau was 23.6 3.2 days. The improvement in range of motion in thermal burn contractures was 41.2 30.3 degrees, that in electrical burns was 31.8 26.8 degrees. The improvement in range of motion in post traumatic contractures was 36.8 27.4 degrees. Least improvement was seen in contractures due to cellulitis (6.5 16.2 degrees). Post cellulitis contracture was however not used for comparison due to different etiological and biomechanical properties. This finding was statistically significant [F(3,86) = 4.25, p = 0.005] (Table 1). There was no significant difference between the response of male and female patients to serial splintage (t = 0.776, p = 0.447). Significant difference was seen in response to therapy based on the joint involved [F(3,86) = 3.36, p = 0.02]. Highest improvement in the range of motion was seen in the metacarpophalangeal joint 49.61 31.3 degrees, followed by elbow (44.28 27.14), proximal interphalangeal (34.5 25.1) and distal interphalangeal joint (27.3 18.8) (Table 2).
1098
burns 39 (2013) 1096–1100
Table 1 – Mean improvement in contracture angle of various etiology in response to serial splintage. Etiology
Improvement (degress)
Statistical analysis
37.4 28.1 41.2 30.3 31.8 26.8 36.8 27.4
F(3,86) = 4.25, p = 0.005
Total Thermal burn Electrical burn Post traumatic
4.
Discussion
Contractures of hand are a distressing problem. Contracture can develop due to a variety of causes. However, an overwhelming majority of contractures seen in our clinical practice are due to thermal burns. Overall, postburn contractures are distressingly common and severe in developing nations and are a significant problem in developed countries as well [3]. Splinting of hand in anatomical position has been described as an effective preventive strategy [4,6]. Several authors have described various modifications of splints and their application techniques [7–9]. Richard et al. have extensively reported the use of static splinting in preventing contractures. The controversies regarding splintage has been extensively reported in the literature and reviewed from time to time [10–14]. There are reports in the literature which have questioned the utility of static splinting. Schouten et al. have suggested that static splinting could in fact counteract its own purpose [14]. Our experience though does suggest that serial static splintage improves the movement range across the joint. Results suggest that significant difference is seen in the range of movement by static splinting in our study. We believe that such application of serial static splinting might have significant role in managing contractures in the developing world. The described therapy protocol gives patients a realistic chance of avoiding surgery and ensures good patient compliance where surgery is eventually required. Serial splinting has been described as a treatment strategy for pre-surgical treatment of contractures. There is considerable dispute regarding the timing of surgical intervention in post burn deformities. Some authors have advocated early surgical intervention while others tend to wait for about 6 months for the scars to mature [15–18]. It has been reported that waiting for some time decreases the risk of postoperative infections [3]. In our practice often patients have a waiting period of about two to three months between first visit to the out patient department and the surgical correction of the deformity. The current practice is dictated in part by the overwhelming case load and also the socio-economic status of
Table 2 – Mean improvement in contracture angle across various joints in response to serial splintage. Joint Metacarpophalangeal joint Elbow Proximal interphalangeal Distal interphalangeal
Improvement (degrees)
Statistical analysis
49.61 31.3 44.28 27.14 34.5 25.1 27.3 18.8
F(3,86) = 3.36, p = 0.02
the population treated by us. The present study attempts to devise a treatment strategy in this waiting period so as to decrease the magnitude of the final surgical intervention required and to ensure good patient compliance. In the present study, thermal burn was the most common cause of injury leading to contracture (36.7%), followed by trauma (35.6%), cellulitis (14.4%) and electrical burns (13.3%). The present study did not include any cases of contracture due to degenerative or connective tissue disorders. In the present study, age ranged from 2 to 70 years with a mean of 28.9 13.4 years. Age has been reported to be a significant factor affecting the response of contractures to serial splinting [19]. In the present study, the response to serial splintage was inversely proportional to the age of the patient, i.e. the response decreased with increasing age of the patient. However, this correlation was not statistically significant. (R = 0.21; p = 0.15). Stern et al. have concluded that the amount of time required for the serial stretching depends on age of patient, age of contracture and severity of the deformity [19]. In the present study, mean time taken to achieve plateau was 23.6 3.2 days. Plateau was achieved earliest in thermal burns. No correlation was found between age of the patient and the time required to achieve plateau. The authors acknowledge the fact that literature suggests that the time to achieve plateau is upto 6 weeks. However, in our study the plateau was achieved in a little under 4 weeks. The duration of contracture from the time of injury which has been described as the age of contracture also affects the response to serial splinting [16,19]. In the present study, as the age of contracture increased, the increase in range of motion in response to therapy decreased. The contractures presenting within 1 year of injury showed better response to therapy as compared to those presenting late (40.48 26.2 vs 38.15 28.6 degrees). However, this correlation was not statistically significant (t = 0.33; p = 0.74). The mean range of motion present across all joints before starting the therapy was 54.7 23.6 degrees [14]. The mean improvement in contracture angle obtained by serial splintage was 37.4 28.1 degrees. This translates into a 68.3% improvement in the range of motion. Bennett et al. have described their serial casting technique with a mean increase of range of motion of 54% with minimal complications [1]. Similar to their study, serial splintage was well accepted by our patients. In our study, the need for surgery was eliminated in 12.6% cases. Bennett et al. have documented that in their series, the need for surgery was eliminated in 8 of 15 patients (53.3%). This is in contrast to the present study. However, the present study is a much larger series and includes various etiologies of contracture. In the present study, complete correction was seen in 28.7% of thermal burns. None of the cases of electrical, traumatic or infective burn showed complete correction of the deformity. It can be safely concluded that in thermal burns, while patients are awaiting surgery, the partaking of stretching exercises and splinting will improve their joint and mobility. This can allow surgery to be safely delayed until the scar is mature [1]. The improvement in range of motion in thermal burn contractures was 41.2 30.3 degrees, that in electrical burns
burns 39 (2013) 1096–1100
was 31.8 26.8 degrees. The improvement in range of motion in post traumatic contractures was 36.8 27.4 degrees. This finding was statistically significant [F(3,86) = 4.25, p = 0.005]. There was no significant difference between the response of male and female patients to serial splintage (t = 0.776, p = 0.447). Post inflammatory contractures are dense contractures owing to the intense inflammatory and fibrotic response during the healing phase. Pain present during the inflammatory phase precludes joint mobilization and hence promotes formation of contractures. Some infective pathologies are chronic and thus lead to progressive shortening of the joint [20]. It is plausible that contractures secondary to inflammation are associated with tough scars due to severe fibrosis and hence may not respond to conservative measures. Significant difference was seen in response to therapy based on the joint involved [F(3,86) = 3.36, p = 0.02]. Highest improvement in the range of motion was seen in the metacarpophalangeal joint 49.61 31.3 degrees, followed by elbow (44.28 27.14), proximal interphalangeal (34.5 25.1) and distal interphalangeal joint (27.3 18.8). The healing phase of injured tissue is an important time for intervention. As surgical intervention may not be possible or indicated immediately, conservative measures like serial splinting are important tools. When movement does not put the joint through a full range of motion and daily passive range of movement or posturing does not adequately maintain range, adaptation of the muscle results in contracture [21]. This adaptation is a combination of shortening of muscle fibers and remodeling of muscle connective tissue [20,23]. It is also accompanied by changes in the skin and periarticular tissues [24,25]. When safe forces are applied to tissues statically or cyclically, they demonstrate a transient lengthening depending on the viscoelastic properties of the tissues. This elongation reverses once the force is relaxed. This elastic response is associated with unfolding of tissue and temporary realignment of collagen fibers within the connective tissues [21]. In the present study, no significant difference was found in the response to therapy with regards to the duration of contracture. Our experience and conventional wisdom is that early contractures respond better to these conservative measures. However, it is plausible that even the older contractures respond adequately to serial splinting. This is a finding which requires further study. It is possible that in absence of bony blocks, even chronically scarred tissue may respond to graduated stretching and splinting. However, a larger multicentre trial is needed to establish it as a treatment modality. Literature shows that systemic analysis of splinting as an effective treatment strategy for contractures of upper limb are lacking. The present study demonstrates its use as an adjunct treatment and in appropriate cases as the only treatment. In the developing world, contractures due to burn make up for a significant amount of case load. Data from our center show that burn contractures account for 10– 15% of the surgeries performed by us. Present treatment helps to reduce the contracture angle and in some cases eliminates the need for surgery. It is an effective treatment strategy for patients who are waiting for surgery
1099
and in early presenting thermal contractures. It also increases the patient compliance to postoperative splinting and hence improves the overall treatment results of burn contractures.
Conclusions The preoperative use of splints may lead to lesser surgical intervention and in selective cases elimination of need of surgery. Thermal burns which are the most common cause of post burn contractures in upper limb, show the maximum response to preoperative serial splintage. Patient with minor contracture and supple tissues are fully corrected with splints without the need for surgical intervention. In patients requiring surgical correction, the requirement of skin graft decreases due to decreased contracture angle.
Source of funding Self.
Conflict of interest None.
references
[1] Richard R, Baryza MJ, Carr JA, Dewey WS, Dougherty ME, Forbes-Duchart L, et al. Burn rehabilitation and research: proceedings of a consensus summit. J Burn Care Res 2009;30:543–73. [2] Schneider JC, Holavanahalli R, Helm P, Goldstein R, Kowalske K. Contractures in burn injury: defining the problem. J Burn Care Res 2006;27:508–14. [3] Schwarz RJ. Management of the post burn contractures of the upper extremity. J Burn Care Res 2007;28:212–9. [4] Pandya AN. Principles of treatment of burn contractures. Repair Reconstr 2002;2:12–3. [5] [accesed 31.05.12]. [6] Mani MM, Chhatre M. Reconstruction of the burned lower extremity. Clin Plast Surg 1992;19:693–703. [7] Kwan MW, Ha KW. Splinting program for patients with burnt hand. Hand Surg 2002;7:231–41. [8] Yotsuyangi T, Yokoi K, Omizo M. A simple and compressive splint for palmar skin grafting in young children with burns. Burns 1994;20:55–7. [9] Van Straten O, Sagi A. ‘‘Supersplint’’: a new dynamic splint for the burned hand. J Burn Care Rehabil 2000;21: 71–3. [10] Richard R, Miller S, Staley M, Johnson M. Multimodal verses progressive treatment of techniques to correct burn scar contractures. J Burn Care Res 2000;21:506–12. [11] Richard R, Staley M, Miller S, Warden G. To splint or not to splint: past philosophy and current practice I. J Burn Care Res 1996;17:444–535. [12] Richard R, Staley M, Miller S, Warden G. To splint or not to splint: past philosophy and current practice II. J Burn Care Res 1997;18:61–74.
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[13] Richard R, Staley M, Miller S, Warden G. To splint or not to splint: past philosophy and current practice III. J Burn Care Res 1997;18:250–5. [14] Richard R, Ward RS. Splinting strategies and controversies. J Burn Care Res 2005;26(5):392–6. [15] Schouten HJ, Nieuwenhuis MK, van Zuijlen PP. A review on static splinting therapy to prevent burn scar contracture: do clinical and experimental data warrant its clinical application? Burns 2012;38:19–25. [16] Kucan JO, Bash D. Reconstruction of the burned foot. Clin Plast Surg 1992;19:705–19. [17] Schwarz RJ, Joshi KD. Treatment of post-burn contractures. J Nephrol Med Assoc 2004;43:211–7. [18] Baux S, Mimooun M, Kirsch JM, Zumer L, Berard V. Treatment of elbow contractures in burns. Burns Incl Therm Inj 1987;13:241–4.
[19] Stern PJ, Law EJ, Benedict FE, MacMillan BJ. Surgical treatment of elbow contractures in postburn children. Plast Reconstr Surg 1985;76:441–6. [20]
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns
Serial splintage: Preoperative treatment of upper limb contracture Vinita Puri a, Nishant Khare a,*, N. Venkateshwaran a, Sumit Bharadwaj b, Sushant Choudhary a, Omkarnath Deshpande a, Rupali Borkar c a
Department of Plastic Surgery, Seth GS Medical College & KEM Hospital, Mumbai 12, India Department of Community Medicine, Chirayu Medical College, Bhopal, India c Department of Occupational Therapy, Seth GS Medical College & KEM Hospital, Mumbai, India b
article info
abstract
Article history:
Introduction: The present study aimed to study the efficacy of preoperative splints in
Accepted 4 January 2013
treatment of upper limb contractures and to evaluate the response of contracture to splints depending on the etiology and the joint involved.
Keywords:
Methods: Ninety joints of 42 patients were studied. Patients age, gender, etiology, duration of
Burn
contracture, contracture site and joint and type of contracture was noted. The range of
Contracture
motion of the involved joint was recorded. Serial static splints made of thermoplastic
Hand
material were applied after customizing them for each patient. The range of motion and
Serial splint
percentage movement was recorded at weekly interval and the splints were modified as per
Contracture angle
need. Time taken to reach a plateau stage was noted. To compare the statistical significance between two groups and more than two groups of continuous variable unpaired t-test and one way ANOVA respectively was applied. We considered differences to be statistically significant when the p value was below 0.05. The strength of relationship between the two continuous variables was analyzed by Pearson correlation analysis. Results: Etiological factors were thermal burns (36.7%), electrical burns (13.3%), post traumatic (35.6%) and post cellulitis (14.4%). Age ranged from 2 to 70 years with a mean of 28.9 13.4 years. Sixty-two patients treated were males (68.9%) and 28 were female (31.1%). The mean range of motion present across all joints before starting the therapy was 54.7 23.6 degrees. The mean improvement in contracture angle obtained by serial splintage was 37.4 28.1 degrees. The mean time taken to achieve plateau was 23.6 3.2 days. Maximum improvement was seen in thermal burn contractures (41.2 30.3 degrees). Least improvement was seen in contractures due to cellulitis (6.5 16.2 degrees). This finding was statistically significant [F(3,86) = 4.25, p = 0.005]. Significant difference was seen in response to therapy based on the joint involved [F(3,86) = 3.36, p = 0.02]. Highest improvement in the range of motion was seen in the metacarpophalangeal joint (49.61 31.3 degrees). Conclusions: The preoperative use of splints may lead to lesser surgical intervention and in selective cases obviate surgery. Thermal burns which are the most common cause of contractures of the upper limb, show the maximum response to preoperative serial splintage. Patient with minor contracture and supple tissues are fully corrected with splints without surgical intervention. In patients undergoing surgical correction, skin graft decreases due to decreased contracture angle. # 2013 Elsevier Ltd and ISBI. All rights reserved.
* Corresponding author. Tel.: +91 9619442855. E-mail address: [email protected] (N. Khare). 0305-4179/$36.00 # 2013 Elsevier Ltd and ISBI. All rights reserved. http://dx.doi.org/10.1016/j.burns.2013.01.010
burns 39 (2013) 1096–1100
1.
Introduction
Burn scar contracture has been defined as ‘‘an impairment caused by replacement of skin with pathologic scar tissue of insufficient extensibility and length resulting in a loss of motion or tissue alignment of an associated joint or anatomic structure. Contractures can affect a skin crease, skin juncture, or margin and may secondarily deform adjacent normal structures. Burn scar contractures are labeled according to the antithesis of movement impeded, resultant tissue deviation, or functional deformity’’ [1]. They result from a combination of possible factors – limb positioning, duration of immobilization and muscle, soft tissue, and bony pathology [2]. Upper limb contractures are seen commonly in our clinical practice. They may be due to a variety of causes like burn, trauma and infection. However, contractures due to burns, thermal and electrical, account for an overwhelming majority of these contractures. Failure to seek medical help, inadequate medical care, and inadequate posthealing care are common causes of burn contractures [3]. There are two key elements in burn contracture prevention, namely splinting of the burned area in its anatomic position and regular exercises through each joint’s full range of motion [4]. The same principles can be reasonably applied to contractures of other etiology. Such effective use of splints and mobilization has been described for prevention of contractures. Development of contracture is an ongoing process and may continue for up to 2 years after sustaining the injury [5]. It can thus be posited that any intervention which prevents the progress of contracture should be effective in doing so within this time frame and similarly some attempts at reversing the contracture can be made during this time. Indications for the use of splints in burn care include joint and skin graft protection, positioning to prevent deformity, and positioning to maintain or increase elongation of scar tissue. The principles behind splinting are well established. However, the utilization of splinting is markedly varied among burn therapists, possibly because of the paucity of objective data regarding both intervention parameters and efficacy of splint use [1]. The present study attempts to study the efficacy of preoperative splints in treatment of upper limb contractures and evaluate the response of contracture to splints depending on the etiology. The study is an attempt to provide sufficient data for evaluation of this technique.
2.
Methods
The study was conducted prospectively from September 2008 to April 2011. Ninety joints of 42 patients were studied. Patients age, sex, etiology, duration of contracture, contracture site and joint and type of contracture was noted. The range of motion of the involved joint was recorded. Serial static splints made of thermoplastic material were applied after customizing them for each patient. The therapy protocol consisted of continuous application of the static splint, scar massage with emollient four times a day for 10 min each, passive stretching exercises twice daily for 20–30 min each. The patients were advised to wear the splint continuously and
1097
remove it only at time of exercise, scar massage and when needed for activities like bathing, etc. The therapy was administered at home by their kins or self. All the patients who reported for treatment had already developed contractures at time of initial visit. Twenty-six of the 42 patients were not treated initially at burn care centers and hence did not receive any advise regarding splintage or other forms of therapy. Sixteen of the 42 patients were non compliant to the initial therapy advise. The range of motion and percentage movement was recorded at weekly interval and the splints were modified as per need. Time taken to reach a plateau stage was noted. The discrete variables were reported in percentage and proportion. Continuous variables were reported as mean SD. To compare the statistical significance between two groups and more than two groups of continuous variable unpaired t-test and one way ANOVA respectively was applied. We considered differences to be statistically significant when the p value was below 0.05. The strength of relationship between the two continuous variable was analyzed by Pearson correlation analysis. The analysis was performed using statistical programme (SPSS Version10.0, SPSS Inc., Chicago, USA).
3.
Results
A total of 90 contractures were included in study. Twenty-six of the 42 patients reported that no initial treatment to prevent contracture was offered to them while 16 of 42 patients were non compliant. All the 26 patients who did not receive any initial advise were treated at primary health centers or by local practitioners with no specific training in burn care. Etiological factors were thermal burns (36.7%), electrical burns (13.3%), post traumatic (35.6%) and post cellulitis (14.4%). Age ranged from 2 to 70 years with a mean of 28.9 13.4 years. Sixty-two patients treated were males (68.9%) and 28 were female (31.1%). The mean range of motion present across all joints before starting the therapy was 54.7 23.6 degrees. The mean improvement in contracture angle obtained by serial splintage was 37.4 28.1 degrees. The mean time taken to achieve plateau was 23.6 3.2 days. The improvement in range of motion in thermal burn contractures was 41.2 30.3 degrees, that in electrical burns was 31.8 26.8 degrees. The improvement in range of motion in post traumatic contractures was 36.8 27.4 degrees. Least improvement was seen in contractures due to cellulitis (6.5 16.2 degrees). Post cellulitis contracture was however not used for comparison due to different etiological and biomechanical properties. This finding was statistically significant [F(3,86) = 4.25, p = 0.005] (Table 1). There was no significant difference between the response of male and female patients to serial splintage (t = 0.776, p = 0.447). Significant difference was seen in response to therapy based on the joint involved [F(3,86) = 3.36, p = 0.02]. Highest improvement in the range of motion was seen in the metacarpophalangeal joint 49.61 31.3 degrees, followed by elbow (44.28 27.14), proximal interphalangeal (34.5 25.1) and distal interphalangeal joint (27.3 18.8) (Table 2).
1098
burns 39 (2013) 1096–1100
Table 1 – Mean improvement in contracture angle of various etiology in response to serial splintage. Etiology
Improvement (degress)
Statistical analysis
37.4 28.1 41.2 30.3 31.8 26.8 36.8 27.4
F(3,86) = 4.25, p = 0.005
Total Thermal burn Electrical burn Post traumatic
4.
Discussion
Contractures of hand are a distressing problem. Contracture can develop due to a variety of causes. However, an overwhelming majority of contractures seen in our clinical practice are due to thermal burns. Overall, postburn contractures are distressingly common and severe in developing nations and are a significant problem in developed countries as well [3]. Splinting of hand in anatomical position has been described as an effective preventive strategy [4,6]. Several authors have described various modifications of splints and their application techniques [7–9]. Richard et al. have extensively reported the use of static splinting in preventing contractures. The controversies regarding splintage has been extensively reported in the literature and reviewed from time to time [10–14]. There are reports in the literature which have questioned the utility of static splinting. Schouten et al. have suggested that static splinting could in fact counteract its own purpose [14]. Our experience though does suggest that serial static splintage improves the movement range across the joint. Results suggest that significant difference is seen in the range of movement by static splinting in our study. We believe that such application of serial static splinting might have significant role in managing contractures in the developing world. The described therapy protocol gives patients a realistic chance of avoiding surgery and ensures good patient compliance where surgery is eventually required. Serial splinting has been described as a treatment strategy for pre-surgical treatment of contractures. There is considerable dispute regarding the timing of surgical intervention in post burn deformities. Some authors have advocated early surgical intervention while others tend to wait for about 6 months for the scars to mature [15–18]. It has been reported that waiting for some time decreases the risk of postoperative infections [3]. In our practice often patients have a waiting period of about two to three months between first visit to the out patient department and the surgical correction of the deformity. The current practice is dictated in part by the overwhelming case load and also the socio-economic status of
Table 2 – Mean improvement in contracture angle across various joints in response to serial splintage. Joint Metacarpophalangeal joint Elbow Proximal interphalangeal Distal interphalangeal
Improvement (degrees)
Statistical analysis
49.61 31.3 44.28 27.14 34.5 25.1 27.3 18.8
F(3,86) = 3.36, p = 0.02
the population treated by us. The present study attempts to devise a treatment strategy in this waiting period so as to decrease the magnitude of the final surgical intervention required and to ensure good patient compliance. In the present study, thermal burn was the most common cause of injury leading to contracture (36.7%), followed by trauma (35.6%), cellulitis (14.4%) and electrical burns (13.3%). The present study did not include any cases of contracture due to degenerative or connective tissue disorders. In the present study, age ranged from 2 to 70 years with a mean of 28.9 13.4 years. Age has been reported to be a significant factor affecting the response of contractures to serial splinting [19]. In the present study, the response to serial splintage was inversely proportional to the age of the patient, i.e. the response decreased with increasing age of the patient. However, this correlation was not statistically significant. (R = 0.21; p = 0.15). Stern et al. have concluded that the amount of time required for the serial stretching depends on age of patient, age of contracture and severity of the deformity [19]. In the present study, mean time taken to achieve plateau was 23.6 3.2 days. Plateau was achieved earliest in thermal burns. No correlation was found between age of the patient and the time required to achieve plateau. The authors acknowledge the fact that literature suggests that the time to achieve plateau is upto 6 weeks. However, in our study the plateau was achieved in a little under 4 weeks. The duration of contracture from the time of injury which has been described as the age of contracture also affects the response to serial splinting [16,19]. In the present study, as the age of contracture increased, the increase in range of motion in response to therapy decreased. The contractures presenting within 1 year of injury showed better response to therapy as compared to those presenting late (40.48 26.2 vs 38.15 28.6 degrees). However, this correlation was not statistically significant (t = 0.33; p = 0.74). The mean range of motion present across all joints before starting the therapy was 54.7 23.6 degrees [14]. The mean improvement in contracture angle obtained by serial splintage was 37.4 28.1 degrees. This translates into a 68.3% improvement in the range of motion. Bennett et al. have described their serial casting technique with a mean increase of range of motion of 54% with minimal complications [1]. Similar to their study, serial splintage was well accepted by our patients. In our study, the need for surgery was eliminated in 12.6% cases. Bennett et al. have documented that in their series, the need for surgery was eliminated in 8 of 15 patients (53.3%). This is in contrast to the present study. However, the present study is a much larger series and includes various etiologies of contracture. In the present study, complete correction was seen in 28.7% of thermal burns. None of the cases of electrical, traumatic or infective burn showed complete correction of the deformity. It can be safely concluded that in thermal burns, while patients are awaiting surgery, the partaking of stretching exercises and splinting will improve their joint and mobility. This can allow surgery to be safely delayed until the scar is mature [1]. The improvement in range of motion in thermal burn contractures was 41.2 30.3 degrees, that in electrical burns
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was 31.8 26.8 degrees. The improvement in range of motion in post traumatic contractures was 36.8 27.4 degrees. This finding was statistically significant [F(3,86) = 4.25, p = 0.005]. There was no significant difference between the response of male and female patients to serial splintage (t = 0.776, p = 0.447). Post inflammatory contractures are dense contractures owing to the intense inflammatory and fibrotic response during the healing phase. Pain present during the inflammatory phase precludes joint mobilization and hence promotes formation of contractures. Some infective pathologies are chronic and thus lead to progressive shortening of the joint [20]. It is plausible that contractures secondary to inflammation are associated with tough scars due to severe fibrosis and hence may not respond to conservative measures. Significant difference was seen in response to therapy based on the joint involved [F(3,86) = 3.36, p = 0.02]. Highest improvement in the range of motion was seen in the metacarpophalangeal joint 49.61 31.3 degrees, followed by elbow (44.28 27.14), proximal interphalangeal (34.5 25.1) and distal interphalangeal joint (27.3 18.8). The healing phase of injured tissue is an important time for intervention. As surgical intervention may not be possible or indicated immediately, conservative measures like serial splinting are important tools. When movement does not put the joint through a full range of motion and daily passive range of movement or posturing does not adequately maintain range, adaptation of the muscle results in contracture [21]. This adaptation is a combination of shortening of muscle fibers and remodeling of muscle connective tissue [20,23]. It is also accompanied by changes in the skin and periarticular tissues [24,25]. When safe forces are applied to tissues statically or cyclically, they demonstrate a transient lengthening depending on the viscoelastic properties of the tissues. This elongation reverses once the force is relaxed. This elastic response is associated with unfolding of tissue and temporary realignment of collagen fibers within the connective tissues [21]. In the present study, no significant difference was found in the response to therapy with regards to the duration of contracture. Our experience and conventional wisdom is that early contractures respond better to these conservative measures. However, it is plausible that even the older contractures respond adequately to serial splinting. This is a finding which requires further study. It is possible that in absence of bony blocks, even chronically scarred tissue may respond to graduated stretching and splinting. However, a larger multicentre trial is needed to establish it as a treatment modality. Literature shows that systemic analysis of splinting as an effective treatment strategy for contractures of upper limb are lacking. The present study demonstrates its use as an adjunct treatment and in appropriate cases as the only treatment. In the developing world, contractures due to burn make up for a significant amount of case load. Data from our center show that burn contractures account for 10– 15% of the surgeries performed by us. Present treatment helps to reduce the contracture angle and in some cases eliminates the need for surgery. It is an effective treatment strategy for patients who are waiting for surgery
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and in early presenting thermal contractures. It also increases the patient compliance to postoperative splinting and hence improves the overall treatment results of burn contractures.
Conclusions The preoperative use of splints may lead to lesser surgical intervention and in selective cases elimination of need of surgery. Thermal burns which are the most common cause of post burn contractures in upper limb, show the maximum response to preoperative serial splintage. Patient with minor contracture and supple tissues are fully corrected with splints without the need for surgical intervention. In patients requiring surgical correction, the requirement of skin graft decreases due to decreased contracture angle.
Source of funding Self.
Conflict of interest None.
references
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