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CHAPTER30 Burn contracture surgery
Fig 30.5 Posterior arm ap based on perforating vessel in posterior axillary fold.
development of propeller aps have been widely used for axillary contractures of moderate severity.
More complex aps used for the axilla include the scapular, parascapular
and latissimus dorsi. these may occasionally be indicated for very severe
contractures requiring a very deep release, but are generally somewhat
bulky, and are relatively complex to raise (the scapular aps in particular are
tricky to raise for the less experienced surgeon).
Grafting
Split skin grafting is often necessary in severe axillary contractures where
no local tissue is available to design a ap. The defect for grafting is often
deeply concave; so a tie- over dressing is essential, and a 1:1.5 meshed graft
is often helpful to achieving good graft take. In severe contractures, release
of some bres of the pectoralis major is occasionally required to help with
the release. An abduction splint is used for 2– 3 weeks and physiotherapy
exercises are essential thereafter to prevent graft shrinkage.
Trapezoid ap plus grafting
A trapezoid ap is an excellent method of releasing a broadband axillary
contracture with diuse scarring.
The principle is to use the ap to move stable scarred skin up into the
axilla from the lateral chest wall below the axilla and to place the graft on
the resultant defect on the lateral chest wall (a more favourable site for
graft take than the concave, irregular axilla). Because the graft is not directly
over the joint, more rapid mobilization of the shoulder may be undertaken
(Fig. 30.6).
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THE AXILLA
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Fig.30.6 (A) Flap advancing to axilla. (B)Keep incising at this edge, not undermining.
(C)Flap is advanced to axilla and Zs at margins of ap are close. Defect for skin graft
created by release.
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CHAPTER30 Burn contracture surgery
Fig.30.6 (Contd.)
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THE AXILLA
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CHAPTER30 Burn contracture surgery
Antecubital fossa
Local aps formild/ moderate scarring
A variety of local ap procedures are useful for linear contractures of the
antecubital fossa.
In long linear band contractures involving both the axilla and antecubital
fossa, multiple Y– V plasties oer a simple solution, albeit one which leaves
a long incision and signicant scarring.
For moderately thick linear band contractures, an asymmetric Z plasty
may provide a useful release without excessive additional scarring, as long
as there is skin laxity and adjacent normal skin for the Z aps to be elevated
(see Fig. 30.7).
Propeller ap or island perforator- based ap
The ‘propeller’ principle has been applied using a single island ap based
on a perforating vessel. The ap may be rotated by as much as 180°. There
tends to be many perforating vessels close to the elbow joint, and hence a
ap can be planned and transposed into a defect after release of a moderately broad contracture.
Increasingly, such aps are being termed ‘propeller’ aps. Alternative descriptive terms for the propeller ap are island perforator ap or ad hoc
perforator ap (Fig. 30.8).
Diuse contractures ofantecubital fossa
For diuse contractures, incisional release and skin grafting is reliable. The
‘shtail’ design is commonly used, care being taken to release to the mid
lateral lines. Agood alternative is to use an incisional release with Z plasties
at each margin.
Skin laxity
Fig.30.7 Asymmetric Z plasty. The 90° limbs of the aps are placed in the scar and
should be incised through full thickness of scar but not undermined. The 60° aps in
healthy skin are undermined.
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ANTECUBITAL FOSSA
Sometimes incisional release at the elbow crease tends to carry dissection deep, requiring division of the cephalic vein and reaching close to the
brachial artery and median nerve which lie relatively supercial at the line
of the elbow.
A technique which avoids the problem of excessively deep release at the
line of the elbow crease is to use two incisions, proximal and distal to the
elbow crease line, about 6cm apart, so that a patch of skin is preserved
over the antecubital fossa and grafts are inserted proximal and distal to
this. This allows an eective contracture release without excessively deep
dissection (Fig.30.9).
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Fig.30.8 (A) Island or ad hoc perforator ap. Perforator in base of ap. (B)Islanded
and transposed.
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CHAPTER30 Burn contracture surgery
Fig.30.9 Double incisional release at elbow. This leaves skin intact over median
nerve and brachial artery and allows the skin grafts to be inset to good beds over the
brachial and forearm muscles.
For severe contractures of the antecubital fossa, a very extensive release
may be required, and sometimes this may include release biceps tendon
and some bres of brachialis. In this event, larger aps are required at the
antecubutal fossa. The indication for this is a release, which extends down
to brachial artery and median nerve, and/ or a tendon lengthening procedure. If a ap is essential, a proximally based radial forearm ap, or a
distally based medial or lateral arm ap may be used. Almost always, the
donor defect for these aps has to be skin grafted. A free ap may be a
good option for such severe cases.
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ANTECUBITAL FOSSA
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CHAPTER30 Burn contracture surgery
The olecranon
Quite commonly, the olecranon becomes exposed after ame burn injury
of the upper limb. While not strictly speaking a contracture, this is often a
problem for the patient, with persistent scar breakdown and discomfort.
Often, this will gradually heal with time, so it is worth persisting with
dressings and topical and systemic antibiotics.
If the area persistently fails to heal, a variety local transposition or advancement aps may be used, depending on where there is local skin laxity
(skin free of scarring).
If there is no local skin laxity, a distally based lateral arm fascial ap or a
proximally based posterior interosseous ap may be used to provide thin
tissue to cover the olecranon.
The wrist
Flexion contracture of the wrist is a common consequence of ame burn
injury or electrical burn.
After burns of moderate depth, release and medium thickness split skin
graft or full thickness graft will commonly produce a satisfactory result.
The wrist should be splinted in extension for several weeks afterwards
and at night for several months.
Occasionally, in more severe contractures it is helpful to sacrice the
exor carpi radialis tendon, preserving the fascia over the deeper exor
tendons. (The palmaris longus can always be sacriced.)
After very deep burns, such as an electrical burn, release may expose
tendons and median nerve (which may be damaged and may even require
reconstruction). In this event, a ap is required to cover the exor aspect
of the wrist.
Free aps oer most exible coverage and tissue components for these
complex defects with the possibility of bi- layered aps of skin and fascia to
wrap tendons or nerve grafts, and various other composite tissue options.
The pedicled groin ap is a reliable option for these defects. Occasionally,
the much simpler Becker ap may be transposed (distally based) from the
ulnar aspect of the forearm to cover the exor aspect of the wrist if the
perforating vessel from the ulnar artery is intact.
For linear band contractures of the wrist, Y– V plasties or multiple Z
plasties are suitable.
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THE WRIST
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