Contracture managment.pptx

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1. Presenter dr zebiba Classification & Management post burn contracture of upper extremities

2. outline Introduction Prevention of post burn contracture Classification Management Summary Reference

3. Introduction Scar contracture is the common leading cause disabilities in burn patient W ound healing the wound & scar edge contract approaching the neighboring sxr Scar contracture mostly occur due to physical inactivity & patient preference to position comfort Prevention of burn contracture by proper positioning ,splinting & physiotherapy is the best way to avoid contracture

4. Contraction is normal dynamic physiological process by which the healing area decrease in size due to myofibroblast Retraction is consequence of contraction over surrounding normal tissue Contracture is final result of this vicious process over the joint area which affect the joint movement

5. Factor that increase risk of contracture include -depth of injury -location -poor dressing , splinting and physiotherapy -delay in surgical RX

6. Prevention of post burn contracture Body position and splinting -neck in slight extension -axilla in abduction 90-120 degree -elbow in extension -wrist in 30 degree extension -hand MCP 70 degree of flexion IP extension thumb palmar abduction Elevation of extremities

7. Prevention Physiotherapy Early excision and grafting Intermediate phase of recovery continues use of splint and pressure dressing is important

8. Classification MASCC universally valid for all joint to provide idea severity of & algorithm for RX -three basic measurement width ,height & length its relative to affected joint -width narrow or wide -length short or long -height high or low

9. MASCC has four type -type A narrow + long or short + high -type B narrow + long or short +low -type C wide + short +low -type D wide +short + high -Group 1 narrow aren’t sever in term of functional impairment RX local rearengment of tissue ,graft -group 2 wide scar cause sever functional impairment RX is by FC or perforator based flap

10. Management Preoperative evaluation -identify scar band which cause contracture -assess degree of contracture & motion of joint ,NV -inspect local soft tissue quality -hand look for the web space -examine entire extremities -look for donor site - xray of the joint

11. Principle contracture release -contracture release always start from proximal joint & whose correction give maximum benefit -never graft bare structure and central part of joint -always try to cover central part of joint with flap -one extremities at time -always consider use of tourniquet

12. -always try to achieve maximum release on table -before putting graft or flap put the hand -for scar release the incision is made in scar across the joint in line with axis of rotation -all fibrous tissue should be removed

13. - the scalpel used by pushing method not slicing -always be aware of the critical sxr that can be injured -preserve & reconstruct sxr that stabilize the joint -never expect perfectly planned flap will fit as planed -don’t delay surgery especially in children

14. Non surgical treatment Pushing or pulling of extremities that stretch the scar & the tissue -this can be achieved by serial splint -skeletal traction

15. Axilla Area bounded by anterior & posterior axillary fold Cause of concavity of axilla with full thickness burn if not excised & grafted early there risk for significant contracture ~27% pt develop contracture with early excision & graft or with superficial burn compared with 95% develop contracture when no splint is used

16. Axillary contracture can be classified -1 linear scar contracture at either axillary fold -2 with adjacent tissue scarring -3 both fold is involved with spare cupola -4 entire axilla is involved Type 1 z plasty , yv advancement flap ,graft Type 2 graft ,z plasty , fasciocutaneous flap Type 3 & 4 faciocutaneous , parascapular , LD flap

17. Anterior fold we can use the uninvolved medial , lateral side , lateral thoracic wall Posterior fold transposition flap from lateral ,medial wall , faciocutaneous flap from posterior trunk, long head of triceps ms Both web contracture with spared cupola for larger defect we may need two flap for release should be RX as isolated problem Total axillary contracture graft, parascapular , LD flap , pectorals major ms flap , free flap

18. Surgical technique Z plasty -multiple z ,3/4 z plasty or double opposing can be used if adjacent tissue is spared y/v advancement flap used for minor contracture Inner arm flap can be used for anterior web contracture based on ulnar collateral artery FC flap based on medial septocutaneous vessel from direct branch from brachial artery Triceps long head Free flap & tissue expander

19. Thoracodorsal perforator flap

20. Post operative period -splinting especially for graft -physiotherapy Complication -brachial plexsus injury -graft failure ,flap necrosis -recurrence contracture -transposition of axillary hair

21. Elbow and wrist E lbow contract usually in flexed position and wrist in either flexed or extended Thorough physical exam is important Release Surgical -z plasty -graft -flap for sever case of contracture Thick non meshed STSG can be used after elbow and wrist contracture release if joint is supple , NV sxr non exposed

22. For simple limited band contracture we can use z plasty or v/y flap Sever case elbow contracture we use flap like medial & lateral arm ,PIA ,radial forearm flap ,LD flap For wrist PIA ,groin flap Free tissue transfer ,tissue expander

23. Post op -splint is required -physiotherapy

24. Hand contracture Restoring hand function is primary goal Palmar contracture mostly seen in pediatrics or adult with seizure disorder Treatment -FTSG or STSG can be used -flap

25. Web space deformity Web space contracture is due to scar band obliterating the dorsal aspect of the web classification- grade 1 ¼ distance b/n MP & PIP -grade 1 ½ distance -grade 3 ¾ - grade 4 >3/4 -surgical RX VM plasty , four flap z or jumping man -as grade increase there is need for graft increased

26. Adduction contracture its usually 1 st web space problem -It is due to muscle problem -RX the skin is released with 4 flap z or jumping man & adductor muscle is released Finger contracture tendon s & joint capsule may contribute -RX release of contracture and graft -in case of NV exposed flap

27. Extension contracture common due to thin dorsal skin -RX surgical release graft , 3/4 z plasty for small MCP joint defect ,PIA ,groin flap -fat grafting

28. summary Prevention of post burn contracture is the best way to avoid contracture Thorough physical examination Post operative splint and physiotherapy

29. Reference Functional & aesthetic reconstruction of burn Total burn care Global reconstructive surgery Burn surgery reconstruction & rehabilitation Sever skin contracture management