THE GENERAL METHOD FOR A BROAD CONTRACTURE

Wait until the patient’s burn has healed completely.

ANAESTHESIA Ketamine or general anaesthesia. This is not a task for the minor theatre. Check that the patient’s haemoglobin is over 10 g/dl. Have blood cross matched.

Start by taking skin from the donor site. When his contracture is straightened out, you will need more skin than you expect.

Infiltrate into and under the contracture a mixture of saline 80 ml, 2% lignocaine 20 ml, adrenaline 1:1000 0.5 ml, and preferably hyaluronidase 1 ampoule (’jungle juice’ see A 5.4). This solution will: (1) Demonstrate the tissue planes more clearly. (2) Allow you to separate the scar more easily. (3) Control bleeding. (4) Reduce the amount of general anaesthetic he needs.

Cut through the scar down to the patient’s subcutaneous tissue, in the middle of the contracture. Keep it under tension as you do so. If necessary, cut right down to his tendons. If possible, separate the scar from his deep er tissues by blunt dissection. Push your scissors into the tissues, then open them. This will help you to avoid any superficial veins. You will probably be wise not to try to excise the scar, either in the main part of the contracture, or at its upper or lower ends.

CAUTION! (1) Release the contracture first, and then decide if you need to excise any scar tissue. (2) Don’t cut his deep fascia, unless the scar tissue extends right through it. (3) Contractures will take longer to release than you expect. (4) Beware of congested veins, especially in his axilla and neck.

Carry the incision beyond the limits of the scar tissue, and beyond the axes of the joint on each side. If you don’t do this, the contracture will recur. Or, make a double–Y, as in Fig. 58-21; this will reduce the length of the incision you need to make.

Cover the bare area with a sheet split skin graft, and sew it in place. If you are worried about it taking, mesh it.

CAUTION! Graft the exposed raw areas immediately, especially over joints. This will reduce the risk of the contracture recurring, and the risk of infecting the joint.

Splint the patient’s limb in the opposite position to the contracture, until the graft has taken. When the time comes to remove the dressing, do this yourself. Keep him in a night splint for at least 3 months. Review him regularly and add more skin as necessary.

NECK CONTRACTURES FOR RELEASE

If a patient’s chin is contracted down on his sternum as in Fig. 58-18, refer him if you possibly can. His anaesthetic problems are considerable.

ANAESTHESIA You cannot intubate a patient while he has a contracture of his neck. So, give him ketamine, infiltrate the scar with anaesthetic solution, release it, and then, if necessary, intubate him.

METHOD Incise the scar transversely, if necessary almost from ear to ear. Carefully release the scar tissue by blunt dissection to reveal a huge gap in the front and sides of the patient’s neck.

Apply a sheet of split skin graft and a wet cotton wool dressing, as for the axilla. Immobilize his neck with his head well extended. To prevent recurrence, keep his neck in extension.

Apply a soft collar as soon as his skin is soundly healed, and leave it there for at least 6 months. He must wear a night splint for several more months.

If necessary, repeat the procedure, several times if required, to obtain a little more movement each time.

AXILLARY CONTRACTURES FOR RELEASE

Try to restore full abduction and elevation in a single operation. A Z–plasty will probably be best if the contracture is narrow (58.26).

If the patient has a broad contracture, incise the scar as above, and abduct his arm. Apply a large medium thickness split skin graft to the bare areas, and dress it with wet wool (57-7), so as to fill the dome of his axilla. Cover this with plenty of dry wool, and bandage this (preferably with crepe bandages) to include his whole arm as well as his axilla and chest.

If he is a small child, a large ball of cotton wool bandaged into his axilla may hold his arm in the right position.

If he is an older child or an adult, raise his head and back on a suitable support (as for a hip spica Fig. 77-4), and apply a plaster shoulder spica to include his arm and hand, with his arm at 90 from his chest, his elbow flexed, and his wrist dorsiflexed. This is the most comfortable position.

CAUTION! (1) Don’t injure a patient’s axillary vessels or nerves. (2) Don’t hyperabduct his shoulder, or you may paralyse his brachial plexus.

ELBOW CONTRACTURES FOR RELEASE

A large scar may involve the whole flexor surface of a patient’s elbow. Make a cautious transverse incision across the fold of his elbow, starting laterally, and trying to avoid any congested veins. If the whole width of his elbow is involved, extend the incision into healthy tissue beyond the axis of the joint on each side.

Find a fatty layer and then work gently medially. If you have found the right fatty plane, you should be able to slide the scar tissue up and down his arm. When the incision is complete, divide any deeper strands of fibrous tissue.

Fill the large diamond shaped gap with a medium thickness split skin graft. Cover it with a wet cotton wool stent, as in Fig. 57-7. Immobilize his extended and supinated elbow in a cast which should also immobilize his hand. Dress the graft at 7 to 10 days. When it has taken, apply a cast in extension, for at least 6 to 12 weeks. You are operating for a flexion contracture, so lack of flexion will not be a problem.

HAND CONTRACTURES FOR RELEASE

Try one of the dynamic splints in Fig. 58-19. If the patient’s contracture is mild, this may cure it. If it is severe, a dynamic splint may partially correct the deformity, so that operation will be easier.

If a patient’s metacarpophalangeal joints are hyperextended as part of a claw hand, try to refer him, particularly if he presents late with a gross deformity. This is a particularly difficult contracture, because the capsules of his joints may need opening up and freeing. If you cannot refer him, make transverse incisions over their dorsal surfaces, flex them, graft the gap, and splint his hand in the position of function.

If his wrist is hyperextended, and he presents reasonably early, divide the scar transversely, and apply a medium thickness split skin graft-beware of his median nerve and ulnar artery!

If he has contractures on the flexor surfaces of his fingers, incise them transversely well beyond the axis of the joint, and fill the gap with a full thickness graft, or a thick split skin graft sewn into place.

If he is a child, splint his fingers in extension for 3 months, or the contracture will recur. To help the cast stay in place, apply it with his wrist extended. Examine the cast daily at first, and later weekly, to make sure it has not slipped.

If he is an adult, don’t immobilize his extended fingers for more than 10 days. If necessary, use dynamic splints as in Fig. 58-19, and night splints.

If a patient has a very severe finger deformity, you may need to amputate a finger, or arthrodese it in the position of function.

GROIN, KNEE, ANKLE, AND FOOT CONTRACTURES FOR RELEASE

Follow the general method, as described above, taking care to extend the incision well beyond the axis of the joint.

DIFFICULTIES WITH BURNS

If you CANNOT GET SUFFICIENT RELEASE of a contracture in a single stage, release it as much as you can; consider splinting it, leaving it open, trying to release it further in a few day’s time, and then grafting it.

If there is an ULCER within a scar, excise it.

MANY SEVERE CONTRACTURES ARE LARGELY THE RESULT OF POOR CARE