58.24 Preventing contractures

You can minimize all contractures and prevent many of them completely by using quite simple methods. Failure to apply these methods is one of the commonest mistakes in treating burns. Some of them have already been discussed: (1) Prevent full thickness skin loss where possible, by preventing infection from making superficial burns into deep ones (58.20). (2) If skin for grafting is scarce, make sure you always graft burnt joints (58.19). (3) When you graft them use sheets, rather than patch grafts or mesh. (4) Arrange the sheets of grafted skin so that the joins between them go across the flexor surface of a joint rather than along it (58-15). This will avoid lines of healing along a joint that will later form contractures. (5) Before you graft, scrape away most of the granulation tissue, so that only a thin layer remains. This will reduce the subsequent fibrosis under the graft.

The scar tissue that forms a contracture was once granulation tissue. The deeper a patient’s burn, and the longer you leave it ungrafted, the more granulation tissue there will be, the worse his scar, and the greater the risk of contracture—so graft early!

UNGRAFTED GRANULATIONSFIBROSISCONTRACTURES

The great danger of a scar is that as it contracts it will pull part of the patient’s body into an abnormal position, particularly if he is a child, because he will grow but his scar will not. The abnormal position is usually the position of rest, and a bad one for function. Most contractures are the result of burns on the flexor surfaces—they flex a patient’s elbows, his hips, his knees, and his neck, and they adduct his arms, as in A, Fig. 58-18. The exceptions are the extensor contractures of his wrist and fingers, which commonly follow deep burns on the back of his hand.

Preventing contractures is usually a compromise between: (1) Splinting a patient’s burnt joint in extension for several months, which will prevent the contracture, but may stiffen the joint permanently, often in a bad position for function. And, (2) trying to mobilize a burnt joint early, which will increase its mobility, but will not prevent the contracture. The best compromise between splinting and mobility depends on the joint and how cooperative its owner is. For example, a hand has priority for early grafting, and should be mobilized as soon as it is healed. An intelligent and cooperative patient, who can be trusted to exercise and mobilize his burnt joint, and will apply a night splint, can be told to do so. A less intelligent and cooperative one will be best with his joint in a cast in the extended position. For example, go for mobility with a burnt finger of a teacher, but, if an epileptic of subnormal intelligence has burnt his popliteal fossa, put him in a plaster cylinder for several months. These represent the extremes, with other cases you will have to achieve a compromise.

Stiffness is seldom serious until a joint has been immobilized for 3 weeks in an adult or 6 weeks in a child, so the usual compromise is to splint a joint in extension continously , or not more than 3 weeks in an adult (6 weeks f necessary in a child), while the skin over it heals, and then to mobilize it. After this it can be splinted only at night for a few more weeks, if the patient is fortunate, or for many months if he is not. Three weeks immobility allows partial thickness burns to heal, so contractures should not form. It is deep burns which take longer to heal that are at risk.

Use splints and traction to keep a patient’s limb in the opposite position from that of the expected contracture. Use any simple splint that will do this. The dynamic splints in Fig. 58-19, are ideal in the later stages, but in the earlier ones any simple splint is much better than nothing. No two burns are exactly the same, so you will need considerable ingenuity. There are two important kinds of splint: (1)Those applied initially which a patient wears all the time, and (2) those applied later which he only wears at night. Splints need care—don’t let them cause ulcers in newly grafted skin!

A patient’s contractures may continue to form for a year or more after discharge, so continue the appropriate night splinting while he is an outpatient, and see him regularly. Even splinting for a year may be followed by contractures during the next six months. Earlier on, they can form in a few days. If he is the child of a village mother, try hard to make her understand what a night splint is for, and why she must apply it. Only too often you will see a contracture, which you have carefully released, recur, because she did not understand or use the night splint you gave her.

You will need the continued help of a physiotherapist, and if you don’t have one, you will have to train somebody to fill this role. Make sure he understands what he has to do.

Hypertrophic scars can be prevented by applying a pressure garment for several years if necessary, but you will probably find this impractical.

Finally, remember that if a patient lies continually in the same position because of a burn elsewhere, contractures can form in his unburnt limbs, as happened to Pepita in Fig. 58-1!