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Abstract

This study prospectively examined the incidence and severity of large joint contractures after burn injury and determined predictors of contracture development. Data were collected prospectively from 1993 to 2002 for consecutive adult burn survivors admitted to a regional burn center. Demographic and medical data were collected on each subject. The primary outcome measures included the presence of contractures, number of contractures per patient, and severity of contractures at each of four joints (shoulder, elbow, hip, knee) at time of hospital discharge. Logistic regression analysis was performed to determine predictors of the presence and severity of contractures and a negative binomial regression was performed to determine predictors of the number of contractures. Of the 985 study patients, 381 (38.7%) developed at least one contracture at hospital discharge. Among those with at least one contracture, the mean is three contractures per person. The shoulder was the most frequently contracted joint (38%), followed by the elbow (34%) and knee (22%). Most contractures were mild (60%) or moderate (32%) in severity. Statistically significant predictors of contracture development were length of stay (P < .005) and extent of burn (P = .033) and graft (P < .005). Predictors of the severity of contracture include graft size (P < .005), amputation (P = .034), and inhalation injury (P = .036). More than one third of the patients with a major burn injury developed a contracture at hospital discharge, which highlights the importance of therapeutic positioning and intensive therapy intervention during acute hospitalization. Furthermore, this challenges the burn care community to find new and better ways of preventing contractures after burn injury.

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... [11][12][13][14][15] Despite these interventions, BSC formation is a recalcitrant problem occurring at nearly the same frequency for the last four decades. 1,10,[16][17][18] While incidence, prevalence, and demographic variables contributing to the formation of contractures have been investigated in large multicenter studies, there is a paucity in research that investigates the relationship between currently used rehabilitation therapies and their impact on BSC formation. ...
... Dodd and Curreri reported a BSC rate of 28% while more recent reviews place the incidence higher, 30% to 60%. 10,[16][17][18]30 Although as methodologies and patient populations differed, it is difficult to determine if the frequency of contractures is increasing. Static splinting is a time intensive preventative measure that is commonly employed to reduce the incidence of joint contractures. ...
... We limited the review to the wrist, elbow, knee and ankle because these, except for the hand and shoulder, were the joints most commonly affected by BSC and the most commonly splinted joints in the ACT study. 16,18 The major findings of the current study indicate that splinting is often delayed and when it occurs it is correlated with operative intervention. Joints that are splinted have deep burns in their associated CFUs that require grafting. ...
Article
Introduction Burn scar contracture (BSC) is a common pathological outcome following burn injuries, leading to limitations in range of motion (ROM) of affected joints and impairment in function. Despite a paucity of research addressing its efficacy, static splinting of affected joints is a common preventative practice. A survey of therapists performed 25 years ago showed a widely divergent practice of splinting during the acute burn injury. We undertook this study to determine the current practice of splinting during the index admission for burn injuries. Methods This is a review of a subset of patients enrolled in the Burn Patient Acuity Demographics, Scar Contractures and Rehabilitation Treatment Related to Patient Outcome Study (ACT) database. ACT was an observational multicenter study conducted from 2010-2013. The most commonly splinted joints (elbow, wrist, knee and ankle) and their 7 motions were included. Variables included patients’ demographics, burn variables, rehabilitation treatment and hospital course details. Univariate and multivariate analysis of factors related to splinting was performed. P< 0.05 was significant. Results Thirty percent of the study population (75 patients) underwent splinting during their hospitalization. Splinting was associated with larger burns and increased injury severity on the patient level and increased involvement with burns requiring grafting in the associated cutaneous functional unit (CFU) on the joint level. The requirement for skin grafting in both analyses remained independently related to splinting, with requirement for grafting in the associated CFU increasing the odds of splinting 6 times (OR =6.0, 95% CI=3.8-9.3, p<0.001). On average splinting was initiated about a third into the hospital length of stay (LOS, 35 ± 21% of LOS) and splints were worn for 50% (50 ± 26%) of the LOS. Joints were splinted for an average 15.1 ± 4.8 hours a day. The wrist was most frequently splinted joint being splinted with one third of wrists splinted ( 30.7%) while the knee was the least frequently splinted joint with 8.2% splinted. However, when splinted, the knee was splinted the most hours per day (17.6 ± 4.8 hours) and the ankle the least (14.4 ± 4.6 hours). Almost one third had splinting continued to discharge (20, 27%). Conclusions The current practice of splinting, especially the initiation, hours of wear and duration of splinting following acute burn injury remains variable. Splinting is independently related to grafting, grafting in the joint CFU, larger CFU involvement and is more likely to occur around the time of surgery. A future study looking at splinting application and its outcomes is warranted.
... Except for the superficial dermal burns, all deeper burns (2nd degree deep dermal and full thickness) heal by scarring. Scar contracture is the end result of the process of contraction across the joints [2][3][4][5]. This lead to significant functional and aesthetic deformity in patients of thermal wound survivors. ...
... This lead to significant functional and aesthetic deformity in patients of thermal wound survivors. The prevention or minimization of contracture formation is the best way to prevent the morbidity of these patients [2][3][4][5][6][7]. ...
... The scar collagen and elastin are relatively un-cross linked and malleable during their initial deposition [7-8]. Gentle, passive and sustained stretching exercise and splinting exploits this malleability and is an effective technique for the lengthening of bands of scar tissue and increasing range of motion across joints [2]. Figure 2 described the best positions and splints, which could be adopted by treating physicians to prevent joint contracture and fusion deformity in our case. ...
... 2,3,5,7,8 At discharge, the lower extremities seem to be disproportionately affected, although this has not been consistently shown. 3,6,7,9 The current literature on joint contractures following burn injury has not, however, fully examined all the significant factors related to the development of contractures in a consistent manner. The impact of splinting, positioning, exercise and edema control, and common prevention and treatment rehabilitation therapies, for instance, has not been systematically evaluated in a large burn cohort. ...
... In two of the three published prospective studies measuring discharge limROM, joint measurements were performed by predetermined protocol, measuring joints regardless of associated burn injury. 7,9 The finding from an earlier study by Dobbs and Curreri, reporting that contractures seldom happen in unburned joints may explain the lower contracture rate they found in these studies. 5 The most recent multi-institutional study by Schouten et al employed a similar joint selection protocol as the current study. ...
... Despite advances in burn care and expected survival in the majority of patients, burn contracture rates remain high. 3,6,7,9 We report herein an 86.3% contracture rate in 300 patients at discharge and corresponding joint contracture rate of 58.6%. This multicenter study extends the knowledge on burn injury-related limROM at discharge by including joint-specific information and rehabilitation therapies into the assessment of variables related to joint contraction. ...
Article
Burn scar contractures. Existing research on contractures is limited by incomplete analysis of potential contributing variables and differing protocols. This study expands the exploration of contributing variables to include surgery and rehabilitation treatment-related factors. Additionally, this study quantifies direct patient therapy time and patient exposure to rehabilitation prevention therapies. Data from subjects enrolled in the prospective Burn Patient Acuity Demographics, Scar Contractures and Rehabilitation Treatment Related to Patient Outcome Study (ACT) were analyzed to determine variables related to a limited range of motion (limROM) in seven joints and 18 motions (forearm supination) at discharge. Chi-squared and Student’s t-test were used accordingly. Multivariate analysis was performed at the patient and joint motion level to control for confounders. Of the 300-member study group, 259 (86.3%) patients had limROM at discharge. Variables independently related to the development of moderate-to-severe limROM on the patient level were larger TBSA, having skin grafted and prolonged bed rest. Variables independently related to moderate–severe limROM on the joint motion level were the percentage of cutaneous functional unit (CFU) burned (P = .044), increase in the length of stay, weight gain, poor compliance with rehabilitation therapy and lower extremity joint burns. Rates of limROM are increased in patients who had larger burns, required surgery, had a greater percentage of the associated CFU burned, and had lower extremity burns. Attention to adequate pain control to ensure rehabilitation tolerance and early ambulation may also decrease limROM at discharge and quicker return to pre-burn activities and employment.
... www.nature.com/scientificreports/ greatly to its adverse impact [6][7][8] . Individual differences complicate the establishment of a robust method to assess scar contracture severity. ...
... We found that male sex, age < 50, blue-collar work, ≥ 40% TBSA burned, and surgical treatment were significant predictors. We identified burn patients hospitalised in 1064 tertiary hospitals; the rate of re-hospitalisation for scar contracture was 0.97%, quite a low rate beyond authors' expectation when considering that approximately 33-54% of burn inpatients have been reported to suffer from scar contracture at discharge 3,6,17 . It seems to imply a dramatic discrepancy between high morbidity and low re-hospitalisation rate of post-burn scar contracture, even though there is no comparability between our manuscript and those previous studies. ...
... In the present study, univariate analyses indicated that predictors of re-hospitalisation for scar contracture among burn inpatients included male sex, ≥ 40% TBSA burned, and surgical treatment for burns. Similarly, Schneider et al. 6 and Goverman et al. 3 found that TBSA burned and skin grafting are predictors of the occurrence, case frequency, and severity of scar contracture in burn inpatients, whereas female sex was a protective factor. The underlying mechanism of sex in the pathogenesis of post-burn scar contracture remains controversial and association between sex and nature of burns needs to be considered. ...
Article
Full-text available
Scar contracture, a common destructive complication causing increased re-hospitalisation rate of burn survivors and aggravated burden on the medical system, may be more seriously in Chinese population because of their higher susceptibility to scar formation. This study aims to evaluate the prevalence and predictors of scar contracture-associated re-hospitalisation among Chinese burn inpatients. This cross-sectional study screened burn inpatients hospitalised during 2013 to 2018 through the Hospital Quality Monitoring System database, among whom re-hospitalised for scar contracture were identified. Variables including sex, age, occupations, burn area, burn site and surgical treatment were analysed. Potential predictors of scar contracture-associated re-hospitalisation among burn inpatients were determined by univariate regression analyses. Of the 220,642 burn inpatients, 2146 (0.97%) were re-hospitalised for scar contracture. The re-hospitalised inpatients were predominantly men and blue-collar workers, showing younger median age at the time of burns, larger burn sizes, and higher percentage of surgical treatment compared other burn inpatients. Significant univariate predictors of scar contracture-associated re-hospitalisation included male sex, age < 50 years, blue-collar work, ≥ 40% total body superficial area burned, inhalation injured, and surgical treatment. Scar contracture is an intractable complication and a significant factor to increase re-hospitalisation rate among Chinese burn inpatients.
... Except for the superficial dermal burns, all deeper burns (2 nd degree deep dermal and full thickness) heal by scarring the deeper tissues may be affected either due to their involvement in the initial burn injury (e.g., electrical burns) or secondary to the presence of a skin contracture over a prolonged period of many years, which leads to shortening of musculotendinous units and neurovascular structures. The joints may be subluxated or dislocated, with joint capsule and ligaments becoming tight in the direction of the contracture [2] . ...
... Knee post burn scar flexion contractures, making up 22% of large joint contractures affect the leg motion, impair the lower extremity function, present cosmetic defects. The contracted scars undergo (during joint extension) severe tension, tearing, and often are converted to pathologic scarsrough, thick, solid, prone to keloid growth and ulceration [2] . ...
... Scarring is a significant medical problem that affects more than 80 million people worldwide annually and has many etiologies. 1 For example, more than 4.4 million people are injured in motor vehicle accidents, over 2.4 million patients are burned, and thousands of warriors are wounded in military excursions each year. 2,3 In severe burns that afflict about 28,000 patients each year, more than 40% of patients develop hypertrophic scar which leads to hypertrophic scar contractures (HSc). ...
... 2,3 In severe burns that afflict about 28,000 patients each year, more than 40% of patients develop hypertrophic scar which leads to hypertrophic scar contractures (HSc). 1,4 HSc are stiff, shrunken scars that limit mobility, impact quality of life and cost millions of dollars per year in surgical treatment and physical therapy. 5 HSc develop during wound repair, which persists 6-12 months after the initial injury. ...
Article
Full-text available
Dermal scarring from motor vehicle accidents, severe burns, military blasts, etc. is a major problem affecting over 80 million people worldwide annually, many of whom suffer from debilitating hypertrophic scar contractures. These stiff, shrunken scars limit mobility, impact quality of life, and cost millions of dollars each year in surgical treatment and physical therapy. Current tissue engineered scaffolds have mechanical properties akin to unwounded skin, but these collagen‐based scaffolds rapidly degrade over 2 months, premature to dampen contracture occurring 6–12 months after injury. This study demonstrates a tissue engineered scaffold can be manufactured from a slow‐degrading viscoelastic copolymer, poly(ι‐lactide‐co‐ε‐caprolactone), with physical and mechanical characteristics to promote tissue ingrowth and support skin‐grafts. Copolymers were synthesized via ring‐opening polymerization. Solvent casting/particulate leaching was used to manufacture 3D porous scaffolds by mixing copolymers with particles in an organic solvent followed by casting into molds and subsequent particle leaching with water. Scaffolds characterized through SEM, micro‐CT, and tensile testing confirmed the required thickness, pore size, porosity, modulus, and strength for promoting skin‐graft bioincorporation and dampening fibrosis in vivo. Scaffolds were Oxygen Plasma Treatment and collagen coated to encourage cellular proliferation. Porosity ranging from 70% to 90% was investigated in a subcutaneous murine model and found to have no clinical effect on tissue ingrowth. A swine full‐thickness skin wound model confirmed through histology and Computer Planimetry that scaffolds promote skin‐graft survival, with or without collagen coating, with equal safety and efficacy as a commercially available tissue engineered scaffold. This study validates a scalable method to create poly(ι‐lactide‐co‐ε‐caprolactone) scaffolds with appropriate characteristics and confirms in mouse and swine wound models that the scaffolds are safe and effective at supporting skin‐grafts. The results of this study have brought us closer towards developing an alternative technology that supports skin grafts with the potential to investigate long‐term hypertrophic scar contractures.
... Contracture scarring due to graft contraction is one of the most common postsurgical complications. Scar hyperplasia or contracture affects more than 30% of patients, thereby affecting joint function [2,3]. Although skin graft contraction is a physiological response to reduce the wound area, it creates tension across adjacent tissues, causing cosmetic and functional impairment and affecting the quality of life of patients after skin grafting. ...
... This suggests that adequate laser penetration depth is a decisive factor in achieving contracture scar release and functional recovery, and that increased coverage does not result in effective scar release when laser penetration is insufficient. The rationale for fractional CO 2 laser release of scar contracture include (1) vaporization to remove thickened and disordered abnormal collagen, providing space for neocollagen [27]; (2) increasing tissue elasticity and inducing fine collagen production, mainly type III collagen [28]; (3) contributing to fibroblast apoptosis [29]; and (4) attenuating scar-related proinflammatory cytokine secretion in tissues [15]. The laser in HF-LD and combined groups can penetrate into the deeper half of scars, vaporize and remodel the full thickness, which is necessary for releasing contracture scars. ...
Article
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Background: Fractional CO2 laser plays an important role in scar management post split-thickness skin graft by loosening the graft contracture and restoring the smoothness of the surface. However, the optimal treatment protocol remains unknown. This study applied a dual-scan protocol to achieve both releasing and ablation of contracted skin graft. We comprehensively describe this treatment method and compare the efficacy and safety between this dual-scan method and the conventional mono-scan mode. Methods: A hypercontracted scar model after split-thickness skin grafting in red Duroc pigs was established. All scars meeting the inclusion criteria were randomly divided into four groups: high fluence-low density (HF-LD), low fluence-high density (LF-HD), combined group and control group. The energy per unit area was similar in the HF-LD and LF-HD groups. Two laser interventions were performed at a 6-week interval. The efficacy of the treatment was evaluated by objective measures of scar area, release rate, elasticity, thickness and flatness, while the safety was evaluated based on adverse reactions and melanin index. Collagen structure was observed histologically. The animals were followed up for a maximum of 126 days after modeling. Results: A total of 28 contracted scars were included, 7 in each group. At 18 weeks postoperatively, the HF-LD and the combined groups showed significantly increased scar release rate (p = 0.000) and elasticity (p = 0.036) and decreased type I/III collagen ratio (p = 0.002) compared with the control and LF-HD groups. In terms of flatness, the combined group was significantly better than the HF-LD group for elevations <1 mm (p = 0.019). No significant skin side effects, pigmentation or scar thickness changes were observed at 18 weeks. Conclusions: Dual-scan protocol could achieve superficial ablation and deep release of contracted split-thickness skin graft in a single treatment, with similar contraction release and texture improvement compared to a single deep scan. Its main advantage is to restore a smoother scar appearance. Adequate laser penetration was necessary for the release of contracted scars.
... Thus, a limitation in the knee motion, a postural imbalance, and gait disturbances may occur [3][4][5][6]. The aesthetic and psychological effects are also important especially for young population [3,4,6,7]. Depending on the anatomic type of the retraction and the functional impact, many surgical techniques have been described: skin grafts, local flaps and free flaps [1,6,8,9]. However, for mild scar contractures, the balance between restoring function and limited donor site morbidity is not always established. ...
... The post burns contractures are due to a subcutaneous fibrosis which appearance is related to the excessive wound tension in the functional regions [4,7]. They can vary from a simple linear contracture to a total joint retraction. ...
Article
Full-text available
Post burn scar contractures of popliteal fossa may impair leg motion and have serious aesthetic effects. Through a case report, we present a scar contracture reconstruction of popliteal fossa using a multilobed propeller flap“. This flap might be used to treat mild scar contractures with the presence of healthy skin around the recipient site. It allows restoring function, reconstruction with like to like skin and minimal donor site morbidity. Studies on large scale need to be conducted to demonstrate its superiority compared to other local flaps.
... The age distribution is shown in Table I. Out of total 64 hand injuries, most common was fingertip injury 30 (46%) followed by laceration (21), fracture (7), tendon injury (6), amputation (11) and nerve palsy (1). ...
... In our study 32.8% of the cases of the hand surgery were post burn contracture. As described in other studies, these patients were managed with contracture release [11][12][13] with local flap and skin graft . ...
Article
Full-text available
Background: There can be multiple hand problems with which patients can present. Such hand problems can be because of any kind of trauma, birth defects, tumours, infection or other conditions. Hand surgery is a special field of plastic surgery, which deals with these hand problems. The Department of Burns, Plastic & Reconstructive Surgery of Kirtipur Hospital run by Public Health Concern Trust-Nepal has been providing hand surgery service to the patients with these hand problems. Aim of Study: To analyse the various types of surgical hand problems in patients attending Kirtipur Hospital. Material and Methods: It is a cross sectional retrospective observational study of the patients with different hand problems done at the Department of Burns, Plastic & Reconstructive surgery of Kirtipur Hospital from January to December 2016. Results: There were 124 patients who presented with various hand problems. There was male preponderance and the most common age group affected was between 15-60 years. Hand trauma was the most common cause of hand problems followed by post burn contractures. Conclusion: Hand is a complicated organ which can give rise to various problems. Hand surgery is an essential component of reconstructive surgery to deal with these problems.
... Several interventions are available to prevent the development of scar contractures, such as skin grafting, splinting, positioning, or physiotherapy [11À14]. However, even with adequate treatment, contractures are still common worldwide, with its prevalence varying between 38% and 54% at discharge [2,3,8,15]. ...
Article
Full-text available
Objective Burn scar contractures limit range of motion (ROM) of joints and have substantial impact on disability and the quality of life (QoL) of patients, particularly in a Low- and Middle-Income Country (LMIC) setting. Studies on the long-term outcome are lacking globally; this study describes the long-term impact of contracture release surgery performed in an LMIC. Methods This is a pre-post cohort study, conducted in a referral hospital in Tanzania. Patients who underwent burn scar contracture release surgery in 2017–2018 were eligible. ROM (goniometry), disability (WHODAS 2.0) and QoL (EQ-5D) were assessed. The ROM data were compared to the ROM that is required to perform activities of daily living without compensation, i.e. functional ROM. Assessments were performed preoperatively and at 1, 3, 6 and 12 months postoperatively. Results In total, 44 patients underwent surgery on 115 affected joints. At 12 months, the follow-up rate was 86%. The mean preoperative ROM was 37.3% of functional ROM (SD 31.2). This improved up to 108.7% at 12 months postoperatively (SD 42.0, p < 0.001). Disability-free survival improved from 55% preoperatively to 97% at 12 months (p < 0.001) postoperatively. QoL improved from 0.69 preoperatively, to 0.93 (max 1.0) at 12 months postoperatively (p < 0.001). Patients who regained functional ROM in all affected joints reported significantly less disability (p < 0.001) and higher QoL (p < 0.001) compared to patients without functional ROM. Conclusions Contracture release surgery performed in an LMIC significantly improved functional ROM, disability and QoL. Results showed that regaining a functional joint is associated with less disability and higher QoL.
... Over 1 lakh people are affected by burn every year in India and 20 thousands of them die per year. 1 A survey of past few years indicated a mortality rate of between 25-49% for adult and between 6-20% for children. 2 Thousands of victims of burn are mutilated and handicapped every year. 3 Unfortunately, the incidence of post burn contractures is extremely high in our country. ...
Article
Full-text available
Background: Over 1 lakh people are affected by burn every year in India and 20 thousands of them die per year. Post burn contracture is a common sequele occurring after burn. Upper limb contractures are also occurring more commonly because it is most mobile part of body and likely to be involved in burn. There are many studies on management of post burn contractures but literature about prevention of contracture is little, hence this study was conducted. The aim of this study was to recognise various preventive measures to prevent post burn contractures of upper extremity.Methods: This study was conducted in NSCBM Subharti Medical College and Hospital located in Meerut (North India) from October 2012 to October 2014 in Department of Surgery. It was a prospective observational study consisted of 80 cases who presented as acute burn of upper limb admitted in the hospital.Results: In our study early excision with skin grafting was done in 20 patients (25%) while delayed skin grafting was done in 25 patients (31%) while 35 patients (44%) were managed conservatively. In our study 20 patients reported back with a post burn contracture. The reason found was non-compliance to antideformity splint and physiotherapy.Conclusions: Early surgical management of deep burns, physiotherapy, anti-deformity position and proper splintage can significantly reduce the development of post burn contracture.
... Many of the women burn survivors who have been victims of acid attacks, domestic atrocities or survivors who have attempted suicide show instances of eye and lip ectropion. These contractures affect the patient significantly causing both functional limitations and esthetic disfigurements [4]. The objectives of surgical intervention are releasing the scar, restoring cervical movements, appearance and natural profile and avoiding recurrence of contracture. ...
Article
Full-text available
In developing as well as developed world, burn trauma contributes the second most common cause of trauma related death. When burn injury takes longer time time to heal, more likely a post-burn contracture forms. Burns need longer than 3 weeks to heal, produce hypertrophic scars, and form contractures. Hence the critical situation is the patients who do not receive care shortly after their burn, are more likely to develop contractures. Among 125 crores people living in India, 6-7 million people face the burn incident annually. After road accidents, burn remains in the second largest group of injuries. The National Burns Center (NBC) promoted by the Indian Burns Research Society, is India to tackle burns holistically, starting from fresh burns to post deformities. In a developing country like India, post-burn contractures severely deteriorate life and quality of burn patients. Here in this article, we aimed to review and present our free treatment process, “Operation Restore” to correct the functional deformities and help the economically challenged burn survivors to lead a near normal life who could not afford the corrective surgery.
... Contractures are another common complication following severe burns according to Schneider et al. [56] and it was around 1.1% in our study. ...
Article
Full-text available
This prospective analysis is based on clinical forensic examinations and clinical case records of the victims who sustained burns and were admitted during a one-year period since 2017. Of the 90 patients (34 children and 56 adults), 54 % were male with ages ranging from 1 month to 80 years. Males below the age of 20 years (48 %) were highly vulnerable. Education status revealed that most of the patients have an education level below O/L representing 52 % (Ordinary Level/ O/L is similar to the General Certificate of Secondary Education/ GCSE in Cambridge Education System in United Kingdom) and the majority were married (52%). Scalds were seen in 52 %, while flame burns in 28 % cases. Most of the incidents had taken place at home (92%). Burn injuries were most frequently observed on upper extremities (47 %) and the majority were of first degree in nature. Furthermore, this study revealed that 57 % recovered without any complications, while 34 % resulted in scarring or disfigurement. It was highlighted that children are the most vulnerable to in sustaining burns, especially with hot water in domestic settings. The study recommends increasing awareness among parents/guardians regarding safe handling of hot water to minimize such incidents.
... Omuz, dirsek, kalça ve diz bölgelerinde %60'ında hafif, %32'sinde orta ve %8'inde şiddetli fleksiyon kontraktürlerin oluştuğu saptanmıştır. (14) Kontraktürleri önlemede ve tedavi etmede atel ve basınçlı pansuman kullanılmaktadır. Kontraktürlerin önlenmesinde en büyük adım ise yanığın ilk gününden itibaren egzersizlere başlanılmasıdır. ...
... 1,2,9 Even in high-income countries, contractures are still frequently observed in severely burned patients, and reconstructive surgery is often indicated. 10 In the Dutch burn centers, for example, 20.9% of joints with burns develop a contracture and 13.3% of joints undergo reconstructions. 11,12 The principle of contracture release surgery is to release or excise the scar and to cover the defect with tissue that lengthens the scar. ...
Article
Full-text available
Worldwide, many scar contracture release surgeries are performed to improve range of motion (ROM) after a burn injury. There is a particular need in low- and middle-income countries (LMICs) for such procedures. However, well-designed longitudinal studies on this topic are lacking globally. The present study therefore aimed to evaluate the long-term effectiveness of contracture release surgery performed in an LMIC. Methods: This pre-/postintervention study was conducted in a rural regional referral hospital in Tanzania. All patients undergoing contracture release surgery during surgical missions were eligible. ROM data were indexed to normal values to compare various joints. Surgery was considered effective if the ROM of all planes of motion of a single joint increased at least 25% postoperatively or if the ROM reached 100% of normal ROM. Follow-ups were at discharge and at 1, 3, 6, and 12 months postoperatively. Results: A total of 70 joints of 44 patients were included. Follow-up rate at 12 months was 86%. Contracture release surgery was effective in 79% of the joints (P < 0.001) and resulted in a mean ROM improvement from 32% to 90% of the normal value (P < 0.001). A predictive factor for a quicker rehabilitation was lower age (R2 = 11%, P = 0.001). Complication rate was 52%, consisting of mostly minor complications. Conclusions: This is the first study to evaluate the long-term effectiveness of contracture release surgery in an LMIC. The follow-up rate was high and showed that contracture release surgery is safe, effective, and sustainable. We call for the implementation of outcome research in future surgical missions.
... Omuz, dirsek, kalça ve diz bölgelerinde %60'ında hafif, %32'sinde orta ve %8'inde şiddetli fleksiyon kontraktürlerin oluştuğu saptanmıştır. (14) Kontraktürleri önlemede ve tedavi etmede atel ve basınçlı pansuman kullanılmaktadır. Kontraktürlerin önlenmesinde en büyük adım ise yanığın ilk gününden itibaren egzersizlere başlanılmasıdır. ...
Article
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Burn involves the ongoing rehabilitation process, requiring years of hospitalization in a serious hospital. The rehabilitation process is a long, tiring and challenging process, as important as the survival of the burn patient. Because of this reason, the treatment and care process begins when the patient is referred to the health institution due to burns. Mortality and morbidity have been a serious problem in patients admitted to the hospital with the cause of the best and guides for good burn management have been established. In general, in these guides; burn care organization, initial evaluation and stabilization, diagnosis and treatment of inhalation burns, fluid management in burn shock, pain management, escarotomy and fasciotomy in burn care, wound care, surgical management in the burn, surgical treatment of burn scars, prevention and control of infection, antibiotic management, nutrition, rehabilitation, itching management, ethical issues and quality improvement. In this review, the recommendations of current guidelines for burn care are included. It is important that nurses actively involved in all healing periods of the lumbar nerve should provide care in the direction of the guide.
... The dermal elements within the split thickness skin graft ensure integration of the graft into a well vascularized wound bed, closing the fullthickness defect. However, due to the lack of a fully intact dermis providing mechanical support for skin regeneration within the slip thickness skin graft, significant scarring is a common outcome (Varkey, Ding, & Tredget, 2015), Scarring is not only associated with aesthetic issues, in specific anatomical areas, particularly over joint flexor surfaces, significant scarring can cause contractures (Harrison & MacNeil, 2008) and severe functional disabilities (Schneider, Holavanahalli, Helm, Goldstein, & Kowalske, 2006;van Baar et al., 2006). In many burn victims, scarring becomes an enduring life-long debilitating consequence of their injuries (Holavanahalli, Helm, & Kowalske, 2010). ...
Article
MatriDerm is a collagen‐elastin dermal template that promotes regeneration in full‐thickness wound repair. Due to its noncross‐linked status, MatriDerm biodegrades quickly in a wound. Facilitating vascularization and dermal repair, it is desirable for MatriDerm to remain present until the wound healing process is complete, optimizing tissue regeneration and reducing wound contraction. The aim of this study was to investigate the effect of cross‐linking MatriDerm on its mechanical and biological properties and to enhance its regenerative functionality. MatriDerm was chemically cross‐linked and characterized in comparison with noncross‐linked MatriDerm. Scaffold properties including surface morphology, protein release and mechanical strength were assessed. Cell‐scaffold interaction, cell proliferation and migration were examined using human dermal fibroblasts. Scaffold biodegradation and its impact on wound healing and contraction were studied in a mouse model. Results showed that cross‐linked MatriDerm displayed a small reduction in pore size, significantly less protein loss and a threefold increase in tensile strength. A significant increase in fibroblast proliferation and migration was observed in cross‐linked MatriDerm with reduced scaffold contraction in vitro. In the mouse model, noncross‐linked MatriDerm was almost completely biodegraded after 14 days whereas cross‐linked MatriDerm remained intact. No significant difference in wound contraction was found between scaffolds. In conclusion, cross‐linked MatriDerm showed a significant increase in stability and strength, enhancing its durability and cell‐scaffold interaction. in vivo analysis showed cross‐linked MatriDerm had a reduced biodegradation rate with a similar host response. The extended structural integrity of cross‐linked MatriDerm could potentially facilitate improved skin tissue regeneration, promoting the formation of a more pliable scar.
... This is because the majority of the millions of burn victims in our country are treated by general practioners and not by trained burn specialist or plastic surgeons. Management of these contractures account for up to 50% of 4,5 the general plastic surgeon's workload. ...
... Joint burn scar contracture is defined as a process in which normal skin is replaced by pathological scar tissue with insufficient length and elongation capacity, resulting in a reduction in the range of motion or misalignment of the anatomical structures or tissue of the joints involved (1). The incidence of burn scar contracture is between 18% and 50% (2)(3)(4)(5). Functional limitations may affect patients' ability to work and may even affect their daily activities, including opening jars, dressing, and opening doors. ...
Article
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Background: Burn patients often have functional problems due to joint scar contracture. Patients suffering from such contracture often experience considerable limitations in daily life. Therefore, surgical treatment is often necessary. Skin grafts, especially full-thickness skin grafts and flaps remain the most commonly used surgical methods in clinical practice. However, there are no clear guidelines stating which technique is the most effective treatment. Herein, we conducted a retrospective cohort study over 10 years of experience at a single center to investigate whether flaps or FTSGs exhibit a better long-term effect. Methods: We performed a retrospective chart review of patients with joint burn scar contracture and collected data related to patient demographic profiles, and detailed descriptions of the scars, surgical procedures, and follow-up were collected. We performed follow-up evaluation of three aspects: adverse events (recontracture, ache, and pruritus), satisfaction scores for function and aesthetics, and scar quality (Vancouver Scar Scale score). Results: Follow-up results 1 year after surgery from 88 patients were analyzed. In total, 4 (10%) patients in the flap group and 13 (27.1%) patients in the FTSG group had recontracture; the incidence of recontracture was lower in the flap group than in the FTSG group (P=0.043). The functional satisfaction score of the flap group was higher than that of the FTSG group (P=0.027). Moreover, follow-up results 5 year after surgery for 47 patients were analyzed. In total, 1 (4.8%) patient in the flap group and 7 (26.9%) patients in the FTSG group had recontracture; the incidence of recontracture was significantly lower in the flap group than in the FTSG group (P=0.044). The functional satisfaction score in the flap group was higher than that of the FTSG group (P=0.041). In this study, no significant differences in scar quality were observed between the two groups. Conclusions: If conditions permit, the application of different types of flaps may represent a better choice than FTSGs in terms of reducing the recontracture rate and improving joint function.
... Patients who survive are likely to face serious complications, such as burn scar contractures [8,9]. Contractures are commonly defined as the replacement of skin by excessive scar tissue of insufficient extensibility, which may result in reduced range of motion (ROM) of a joint [8,10À12]. ...
Article
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Objective The aim of this study was to assess the development of burn scar contractures and their impact on joint function, disability and quality of life in a low-income country. Methods Patients with severe burns were eligible. Passive range of motion (ROM) was assessed using lateral goniometry. To assess the development of contractures, the measured ROM was compared to the normal ROM. To determine joint function, the normal ROM was compared to the functional ROM. In addition, disability and quality of life (QoL) were assessed. Assessments were from admission up to 12 months post-injury. Results Thirty-six patients were enrolled, with a total of 124 affected joints. The follow-up rate was 83%. Limited ROM compared to normal ROM values was observed in 26/104 joints (25%) at 12 months. Limited functional ROM was observed in 55/115 joints (48%) at discharge and decreased to 22/98 joints (22%) at 12 months. Patients who had a contracture at 12 months reported more disability and lower QoL, compared to patients without a contracture (median disability 0.28 versus 0.17 (p = 0.01); QoL median 0.60 versus 0.76 (p = 0.001)). Significant predictors of developing joint contractures were patient delay and the percentage of TBSA deep burns. Conclusion The prevalence of burn scar contractures was high in a low-income country. The joints with burn scar contracture were frequently limited in function. Patients who developed a contracture reported significantly more disability and lower QoL. To limit the development of burn scar contractures, timely access to safe burn care should be improved in low-income countries.
... Quite often, they are not only multiple in each subject but also very severe and diffuse. The burn subjects are treated by a variety of service providers who aim at closing the raw wounds and this leads to invariable development of wound contraction and scarring 5,6 Despite advances in the overall management of burn injuries, severe post-burn contractures continue to be a formidable foe for reconstructive surgeons in developing countries. ...
Article
BACKGROUND In reconstruction of post burn scar contracture of hand, thumb reconstruction is crucial. Among various flaps that are available for thumb reconstruction groin flap is ideal for large defects and defects also involving 1 st webspace. Modification in groin flap with fenestration provides more inset, splints thumb in abduction thereby maintaining 1 st web space and no soddening of thumb and 1 st web space. METHODS In a 2-year period between 2017 and 2019, fenestrated groin flap was performed. It was done in 12 cases of which 9 were males and 3 were females. RESULTS All 12 patients had Post-burn Dorsal Contracture (PBSC). The time interval between injury and reconstruction ranges from 10 months to 8 years (mean 3.25). All patients after contracture release were reconstructed with fenestrated groin flap in 2 stages. After 2 weeks flaps were divided and remaining insets were given. Donor sites were closed primarily by undermining or resurfaced with SSG where necessary. All flaps survived with no postoperative complication. CONCLUSIONS Based on our experience with fenestrated groin flap, this is an ideal flap after release of dorsal PBSC thumb.
... PROM impairment was classified by the study team based on the amount of end-range passive movement available at each joint, with initial descriptive categories of impairment consistent with those previously described. 13 Shoulder flexion and abduction PROM measurements were classified as normal if maximal PROM was 180 degrees, mild contracture if maximal PROM was 120 to <180 degrees, moderate contracture if maximal PROM was 60 to <120 degrees, and severe contracture if maximal PROM was <60 degrees. Shoulder extension was classified as normal (≥ 50 degrees), mild contracture (32 to <50 degrees), moderate contracture (16 to <32 degrees), and severe contracture (<16 degrees). ...
Article
Objective: To describe and quantify the relationship between limb impairment variables to key functional outcomes. Design: Observational study of 107 participants with unilateral above/at elbow (AE) or below elbow/wrist (BE) amputation. Demographics, prosthesis characteristics, residual limb length (RLL), and prevalence of passive range-of-motion (PROM) restrictions, and strength impairments were described. Correlations between impairment variables were estimated. Linear regressions examined associations between impairment variables and activity performance, HRQoL, disability and prosthesis satisfaction. Results: Prevalence of short/very short BE and AE residua was 25.7%, and 12.5% respectively. Shorter BE RLL was correlated with elbow flexion weakness (r = 0.30) and PROM (r-0.25). Shoulder PROM restrictions were correlated with shoulder (r: 0.27-0.51) and elbow weakness (r: 0.25-0.46). In regressions, Activity performance was worse for those with shoulder flexion PROM restrictions (B = -5.0, p = 0.03) and better for those with flexion restrictions (B = 3.3, p = 0.04) compared to normal PROM. Prosthetic satisfaction was lower for those with limited elbow PROM. Conclusions: Short BE RLL was correlated with impairment of elbow flexion strength and PROM. PROM restrictions were most prevalent at the shoulder and were strongly correlated with weakness in the same planes of motion. Few significant associations were found between impairment variables and outcomes.
... affecting the patient's quality of life (29,30,(32)(33)(34). Therefore, the formation mechanism and treatment methods of HSs have received increasing attention, and methods for effectively eliminating scars have great clinical significance. ...
Article
The aim of the present study was to investigate the expression and role of microRNA-18a-5p (miR-18a-5p) during the formation of hypertrophic scar (HS), and to further explore the molecular mechanisms involved. Downregulation of miR-18a-5p in HS tissues and human HS fibroblasts (hHSFs) was detected by reverse transcription-quantitative polymerase chain reaction. The binding sites between miR-18a-5p and the 3'-untranslated region of SMAD family member 2 (Smad2) were predicted by TargetScan and confirmed by dual-luciferase reporter assay. To investigate the role of miR-18a-5p in HS formation, the effects of miR-18a-5p downregulation or upregulation on hHSFs were subsequently determined. Cell proliferation was detected by an MTT assay, while cell apoptosis was measured by flow cytometry. In addition, the protein expression levels of Smad2, Collagen I (Col I) and Col III were examined by western blot assay. The findings indicated that miR-18a-5p downregulation in hHSFs significantly promoted the cell proliferation, decreased cell apoptosis and enhanced the expression levels of Smad2, Col I and Col III protein and mRNA, whereas miR-18a-5p upregulation in hHSFs exerted opposite effects. Notably, the effects of miR-18a-5p upregulation on hHSFs were eliminated by Smad2 upregulation. In conclusion, the data indicated that miR-18a-5p was downregulated during HS formation, and its upregulation repressed scar fibroblast proliferation and extracellular matrix deposition by targeting Smad2. Therefore, miR-18a-5p may serve as a novel therapeutic target for the treatment of HS.
... Burns are the fourth most common cause of trauma following traffic accidents, falls, and intentional injuries. Statistics show that there are more than a million burn patients in the United States each year, and the relevant treatment costs are up to 4 billion U.S. dollars [1]. Apart from shock and sepsis, scar contraction is also one of the most serious complications of burns, with the incidence ranging from 30% to 90% [2,3]. The firm red scars continue to grow and contract within 1 or 2 years after injury, causing damage to the patient's appearance and severely affecting their physical activities, and finally resulting in emotional trauma and skill loss. ...
Article
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Scar contraction frequently happens in patients with deep burn injuries. Hitherto, porcine dermal extracellular matrix (dECM) has supplied microenvironments that assist in wound healing but fail to inhibit scar contraction. To overcome this drawback, we integrate dECM into three-dimensional (3D)-printed dermal analogues (PDA) to prevent scar contraction. We have developed thermally gelled, non-rheologically modified dECM powder (dECMp) inks and successfully transformed them into PDA that was endowed with a micron-scale spatial structure. The optimal crosslinked PDA exhibited desired structure, good mechanical properties as well as excellent biocompatibility. Moreover, in vivo experiments demonstrated that PDA could significantly reduced scar contraction and improved cosmetic upshots of split thickness skin grafts (STSG) than the commercially available dermal templates and STSG along. The PDA has also induced an early, intense neovascularization, and evoked a type-2-like immune response. PDA's superior beneficial effects may attribute to their desired porous structure, the well-balanced physicochemical properties, and the preserved dermis-specific ECM cues, which collectively modulated the expression of genes such as Wnt11, ATF3, and IL1β, and influenced the crucial endogenous signalling pathways. The findings of this study suggest that PDA is a clinical translatable material that possess high potential in reducing scar contraction.
... The results of these procedures were mostly due to the lack of dermis of the patients. The invention of dermal matrices arose about 40 years ago, to provide the full thickness of the damaged skin with a new dermis, in order to combat the effects of shrink scars [2][3][4][5]. Grafts have a series of drawbacks: their limited availability, the donor site morbidity, and often an aesthetic damage especially in meshed and partial thickness grafts [6,7]. ...
Article
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Background Appearance of dermal matrices has had an incredibly positive impact on the functional and aesthetic aspects in burned patients, and other wounds with loss of subcutaneous tissue. Nevertheless, dermal matrices can be applicable to other reconstructive fields, especially in organs in which the recovery of skin elasticity is essential.Methods From January 2012 to May 2021, all patients with penile wounds treated at our department with dermal matrices were included in the present study. The following aspects of each case were reviewed: patients’ age, wound mechanism, defect location and size, clinical follow-up, and postoperative complications.ResultsFour patients were included in this study. Average age was 27.7 years (range: 15-43 years). The mechanism of penile injury was subcutaneous penile paraffin injection (n=2), electrical burn (n=1) and surgical complication (n=1).We used Matriderm® monolayer in all cases. There were no cases of total or partial loss. In all cases, a good functional and aesthetic result was achieved.Conclusions Use of dermal matrices must be a daily option in our units, both for acute penile wounds and sequelae, and we all must be familiar with their indications, management, and results. A multidisciplinary approach between Plastic Surgery and Urology is highly recommended.Level of evidence: Level V, therapeutic study.
... In children, the force and tension of the scar contracture can affect the growth of the maxilla and mandible that later cause excessive anterior teeth protrusion and crowding [14,15]. Stretching of scar tissues during mouth opening and jaw movement can cause discomfort and pain [12,[16][17][18]. These complications limit access to the oral cavity and disrupt oral hygiene care; the resulting inefficiency increases the risk of developing dental caries and periodontal diseases that later affect the oral health-related quality of life [1,2,[19][20][21][22][23][24][25][26][27][28][29]. ...
Article
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Background: A burn to the face and neck area leaves a visible scar that impacts the victims physically and psychologically. This report was aimed to examine the factors associated with oral health-related quality of life (OHRQoL) in patients with a facial burn injury. Methods: Patients with facial burn who attended the Burn Care Centre in Islamabad, Pakistan were systematically and randomly invited to participate in this cross-sectional study. They underwent extra- and intra-oral examinations and, completed self-administered instruments in the Urdu language. The severity of disfigurement, dental caries experience (DMFT), periodontal disease (CPI) and oral hygiene (OHI-S) statuses were assessed. The validated instruments collected information relating to sociodemographic background, oral health behaviours, OHRQoL and satisfaction with appearance (SWAP). Information relating to the time of the incident, cause and severity (type, TBSA) of the burn were obtained from medical records. The OHRQoL prevalence of impact and severity measures were derived and analysed using simple and multiple, logistic and linear regression. Results: A total of 271 patients had participated in the study. The OHIP-14 prevalence of impact was 94% with mean severity score = 37 unit (sd = 8.5). The most impacted domains were physical pain (87%), psychological disability (87%), social disability (85%) and physical discomfort (83%). The main determinants of oral health-related quality of life were poor clinical oral conditions - particularly caries, and severity deformity. Other risk factors included poor oral health behaviours, psychological distress and longer time elapsed since the incident, and sex (p < 0.05). Conclusion: Dental caries, the severity of the facial deformity, oral health behaviour and time are associated with oral health-related quality of life of patients with facial burns. Oral health behaviour improvement can lower the risk of developing dental problems and oral health-related quality of life impact.
... Small or no improvements in joint ROM were recorded for affected areas at patients' transfer from ICU to the general ward and prior to hospital discharge despite physiotherapy management being given to all patients during hospitalisation. Early physiotherapy rehabilitation of patients admitted with burn injury to prevent complications associated with active joint ROM is supported by other studies (Hanekom et al. 2015;Schneider et al. 2006). It is possible that lack of patient compliance with physiotherapy management or the repeated need for joint immobilisation after multiple surgeries contributed to the decreased ROM recorded at these time points. ...
Article
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Background: Patients with major burns suffer with pain, which impacts their physical function during hospitalisation. Objectives: To describe the demographics, burn characteristics, clinical course, physical function, complications developed after major burns and to establish predictors of non-independent physical function at hospital discharge. Method: Records of all consecutive adult burn admissions to a Level 1 Trauma Centre between 2015 and 2017 were screened retrospectively against our study criteria, using the Trauma Bank Data Registry. Anonymised data from included records were captured on specifically designed data extraction forms. Descriptive statistics were used to summarise findings. A regression analysis was undertaken to establish predictors of non-independent function at discharge. Results: Males represented 87.7% (n = 64) of included records (n = 73). Median age was 38 (interquartile range [IQR]: 22). Thermal burns were most reported (n = 47, 64.4%), followed by median total body surface area (TBSA) 31% and head and arms were most affected (60.3% and 71.2%). Injury severity was high with median intensive care unit (ICU) length of stay (LOS) of 17 (IQR: 34) and hospital LOS 44 (IQR: 31) days. Wound debridement was mostly performed (n = 27, 36.9%) with limb oedema as a common complication (n = 15, 21.7%). Muscle strength and functional performance improved throughout LOS. None of the variables identified were predictors of non-independent function at hospital discharge. Conclusion: Adults with major burns were predominantly male, in mid-life and sustained thermal injury with a high injury severity. Decreased range of motion (ROM) of affected areas, ‘fair’ muscle strength and independent function were recorded for most patients at hospital discharge. Clinical implications: These findings contribute to the limited body of evidence on the profile, clinical course and outcomes of South African adult burn patients.
... (3) two SD below these normative values; or (4) below the functional ROM. For functional ROM, data from Korp et al. [20] were used regarding the wrist, knee, and ankle joints [9] and from Oosterwijk et al. [22] regarding the shoulder and elbow joints [11]. These cut-off points are reflecting the ROM that is used by healthy subjects to complete ADL tasks without compensatory movements (Table 2). ...
Article
Background: Dissatisfaction is being voiced with the generally used way joint flexibility problems are defined (operationalised), i.e. as a range of motion (ROM) one or more degrees lower than normative ROM of healthy subjects. Other, specifically more function-related operationalisations have been proposed. The current study evaluated the effect of applying different operationalisations of joint flexibility problems on its prevalence. Method: ROM data of 95 joints affected by burns of 23 children were used, and data on 18 functional activities (Burn Outcome Questionnaire (BOQ)). Five methods were used to operationalise joint flexibility problems: (1) ROM below normative ROM, (2) ROM below normative ROM minus 1SD, (3) ROM below normative ROM minus 2SD, (4) ROM below functional ROM, and (5) a score of 2 or more on the Likert Scale (BOQ). Results: Prevalence of joint flexibility problems on a group level ranged from 13 to 100% depending on the operationalisation used. Per joint and movement direction, prevalence ranged from 40% to 100% (Method 1) and 0% to 80% (Methods 2-4). 18% of the children received '2' on the Likert Scale (Method 5). Conclusion: The operationalisation of joint flexibility problems substantially influences prevalence, both on group and joint level. Changing to a function-related operationalisation seems valuable; however, international consensus is required regarding its adoption. Trial registration: The study is registered in the National Academic Research and Collaborations Information System of the Netherlands (OND1348800).
Article
Introducción y objetivo El uso de matrices dérmicas ha repercutido muy positivamente en los aspectos funcionales y estéticos del paciente quemado, sobre todo tras la reconstrucción de áreas especiales. Presentamos la experiencia del Servicio de Cirugía Plástica y Quemados del Hospital Universitario Miguel Servet de Zaragoza, España, en el uso de matrices dérmicas tras cirugía de quemaduras agudas o de sus secuelas. Material y método Estudio observacional de recopilación de 88 casos, infantiles y adultos, tratados entre septiembre de 1999 y septiembre de 2019. Las matrices utilizadas fueron Integra® bicapa y Matriderm® monocapa, únicos sustitutos dérmicos permanentes disponibles en el ámbito de nuestra sanidad pública durante los años referidos. Recopilamos datos de sexo, edad, porcentaje de superficie corporal quemada, mecanismo de la quemadura, grado de profundidad y localización del área tratada con matrices dérmicas, si es quemadura aguda o secuela, pérdidas totales y parciales, y mostramos nuestro protocolo de actuación. Resultados Por sexos encontramos 51 varones y 37 mujeres con una media de edad de 37.67 años, con el grupo más numeroso entre 31 y 50 años; 71 casos con quemaduras agudas y en 17 con secuelas. El mecanismo de quemadura más frecuente fue el térmico (81%). La localización de uso más frecuente fue la extremidad superior con 61 casos. En 67 casos utilizamos Matriderm® de 1 mm, en 13 Integra® bicapa y en 8 ambas matrices en el mismo paciente. La SCQ media de los pacientes tratados por quemaduras agudas fue del 11.7%. Constatamos 4 casos de pérdida total (1 Integra® bicapa y 3 de Matriderm® monocapa) y 11 casos de pérdidas parciales. Conclusiones El uso de matrices dérmicas debe de ser cotidiano en nuestras unidades, tanto para quemaduras agudas como para secuelas, y es necesario familiarizarse con sus indicaciones, manejo y resultados para incluirlas en nuestras escalas reconstructivas.
Article
Introduction: Despite many advances in burn care, the development of extremity contracture remains a common and vexing problem. Extremity contractures have been documented in up to one third of severely burned patients at discharge. However, little is known about the long-term impact of these contractures. The purpose of this study was to examine the association of extremity contractures with employment after burn injury. Methods: We obtained data from the Burn Model System database from 1994 to 2003. We included in the study cohort all adult patients who were working prior to injury and identified those discharged with and without a contracture in one of the major extremity joints (shoulder, elbow, wrist, hip, knee and ankle). We classified contracture severity according to mild, moderate and severe categories. We performed descriptive analyses and predictive modeling to identify injury and patient factors associated with return to work (RTW) at 6, 12, and 24 months. Results: A total of 1,203 participant records met criteria for study inclusion. Of these, 415 (35%) had developed a contracture at discharge; 9% mild, 12% moderate, and 14% severe. Among 801 (67%) participants who had complete data at 6 months after discharge, 70% of patients without contracture had returned to work compared to 45% of patients with contractures (p < 0.001). RTW increased at each subsequent follow-up time point for the contracture group, however, it remained significantly lower than in no-contracture group (both p < 0.01). In multivariable analyses, female sex, non-Caucasian ethnicity, larger burn size, alcohol abuse, number of in-hospital operations, amputation, and in-hospital complications were associated with a lower likelihood of employment. In adjusted analyses, discharge contracture was associated with a lower probability of RTW at all 3 time points, although its impact significantly diminished at 24 months. Conclusions: This study indicates an association between discharge contracture and reduced employment 6, 12 and 24 months after burn injury. Among many other identified patient, injury, and hospitalization related factors that are barriers to RTW, the presence of a contracture at discharge adds a significant reintegration burden for working-age burn patients.
Article
After transplantation, skin grafts contract to different degrees, thus affecting the appearance and function of the skin graft sites. The exact mechanism of contracture after skin grafting remains unclear, and reliable treatment measures are lacking; therefore, new treatment methods must be identified. Many types of centripetal contraction forces affect skin graft operation, thus leading to centripetal contracture. Therefore, antagonizing the centripetal contraction of skin grafts may be a feasible method to intervene in skin contracture. Here, we propose the first reported mechanical stretching method to address contracture after skin grafting. A full-thickness skin graft model was established on the backs of SD rats. The skin in the experimental group was stretched unilaterally or bi-directionally with a self-made elastic stretching device, whereas the skin was non-stretched in the control group. The rats were sacrificed 2 weeks after stretching. The area, length and width of the skin were measured. The grafts were cut and fixed with formalin. Routine paraffin sections were stained with hematoxylin-eosin (HE), picric acid-Sirius red, Victoria blue and anti-alpha-smooth muscle actin (SMA). Mechanical stretching made the graft lengthen in the direction of the stress and had an important influence on collagen deposition and alpha-SMA expression in the graft. This method warrants further in-depth study to provide a basis for clinical application.
Article
Background: Keloids and hypertrophic scars often result after skin trauma. Currently, intralesional triamcinolone acetonide (TAC) is the criterion standard in nonsurgical management of keloids and hypertrophic scars. Intralesional verapamil may be an effective alternative modality, but it has been insufficiently studied. Accordingly, the study authors conducted a systematic review and meta-analysis of randomized controlled trials to compare the efficacy and safety of the two drugs. Methods: The study authors systematically searched the MEDLINE, EMBASE, Cochrane Library, and China National Knowledge Infrastructure databases for relevant trials published in any language through September 2018. Results: According to the four studies included in this review, TAC improved scar pliability and vascularity more than verapamil after 3 weeks (P < .05). For scar height and scar pigmentation, no statistical difference was observed between the treatments (P > .05). The difference in effects on symptoms was not statistically significant (P = .89). For pain and telangiectasia, no statistical difference was observed (P > .05). Verapamil resulted in fewer cases of skin atrophy (P < .05). Conclusions: It appears that TAC is more effective than verapamil for improving scar pliability and vascularity in keloids and hypertrophic scars after 3 weeks of treatment. However, verapamil has fewer adverse drug reactions than TAC, which allows for a longer treatment period and the possibility that it might be effective for patients who cannot receive TAC.
Chapter
Various treatment modalities, such as surgical treatment and conservative treatment, including steroid injection, silicone gel sheeting, pressure treatment, and laser treatment, are available for treating scars. Assessment of the treatment outcome is crucial for determining appropriate treatment modality. In this chapter, we introduce assessment tools for scars. First, we address subjective assessment using scar rating scales in chronological order. The rating scales assess the main features of scars. They are simple, easy to use, noninvasive, fast, and inexpensive. Therefore, they are suitable for use in clinical practice. Second, we address objective assessment using devices for the measurement of scars. We categorize the devices according to the clinical scar features, namely color, thickness, pliability, surface area, and volume. The objective assessment of scars is quantitative, accurate, reliable, reproducible, and valid. Thus, the devices can detect small improvements. However, a small improvement in the treatment outcome may not meet the expectations of patients. Nevertheless, assessment of the outcome using devices is appropriate for research purposes.
Article
Conventional skin grafting procedures such as suturing and stapling are accompanied by pathologic scarring with functional and psychological sequelae; severe scars need a prolonged recovery period, increasing the chance of wound infections or graft contraction. The present study develops a novel bioadhesive delivering dual drugs to minimize scar formation and accelerate wound healing during full-thickness skin grafting. The bioadhesive is prepared via coacervation of a mussel protein and shows high adhesive strength in both porcine skin and in vivo rodent models; furthermore, it sustainably releases dual drugs (allantoin and epithelial growth factor) to enhance re-epithelialization and collagen deposition while simultaneously reducing scar formation. The proposed dual-drug-in-bioadhesive coacervate may ideally meet the requirements of the wound healing process and is a promising candidate for sutureless full-thickness skin grafting.
Article
Background: Fibrin sealant has been used for skin grafting in anatomically difficult facial areas. Although biodegradable, an excess of fibrin sealant may inhibit skin graft healing by inhibiting diffusion at the graft-recipient bed interface. The impact of fibrin sealant volume on graft healing was examined in a rat full-thickness skin graft model. Methods: Seventy-two full-thickness 2.5 × 2.5-cm skin grafts were used on the dorsum of male Sprague-Dawley rats. The grafts were treated with three different volumes of fibrin sealant placed onto the recipient bed: 0.0 mL or normal saline (group 1), 0.1 mL (group 2), and 0.4 mL (group 3). Graft healing and complications were assessed using digital photographs and necropsies on postoperative days 3, 7, and 21. Results: Group 3 showed the greatest graft contraction on days 3 and 21, while group 2 showed the least contraction on all 3 postoperative days (P = 0.002, 0.004, and <0.001, respectively). Histopathologic analysis showed inflammatory foreign body reactions in group 3 on days 3 and 7, and less vascular density on day 21 (P = 0.003). Group 1 showed the highest incidence of hematoma (P = 0.004). Conclusion: An excess volume of fibrin sealant may produce pathologic wound contraction in skin grafting because a skin graft lacks a vascular pedicle and is highly dependent on diffusion from the host environment. Before using fibrin sealant for skin grafting in facial areas where the aesthetic outcome is important, the appropriate volume to use can be determined.
Article
Burns to the palmar aspect of the hand are prevalent in young children. The development of scar tissue across the flexor surface of the hand combined with the years of growth ahead may result in considerable complications. This study was undertaken to describe outcomes of early and intensive use of a palm and digit extension orthosis with the elbow immobilised at 90° flexion following a palmar hand burn. A retrospective review of 107 children (mean age 18 months [SD 10]) treated at a statewide Paediatric Burns Unit from 2012 to 2016 was performed. Three children (3%) developed contracture during the 24-month study follow-up period. The other 104 children (97%) had full ROM at 24 months or at either the point of discharge or loss to follow-up. Early signs of contracture, defined as loss of full movement or significant banding, developed in 26 children (24%) in the first 9-months after burn. With intensive physiotherapy, 23 children regained full movement by 12-months after burn. Children who did not achieve complete wound healing at 1-month after burn and children with hypertrophic scarring at 2-months after burn were significantly more represented among cases of early signs of contracture (p=.013). When undertaken with regular clinical review, early and intensive use of a palm and digit extension orthosis can maintain full extension of the palm and digits in children after palmar burn.
Article
Pediatric burn injuries are frequently complicated by burn scar contractures that often create functional limitations. Usually release followed by skin grafts, local flaps or tissue expansion is adequate. In rare instances, when the contracture is severe and simpler forms of reconstruction have failed, microsurgical free tissue transfer becomes essential. Even though in pediatric patients it can be technically more demanding and there is a reported risk of vasospasm, free tissue transfer has proven to be a good alternative. It is a one-stage procedure that guarantees decent functional outcomes. The perforator anterolateral thigh flap is a workhorse flap in microsurgery. The versatility of this flap allows it to be used in various anatomic locations. In this paper we report its use in neck, wrist, foot and face reconstructions. Flap success rates were 100%, with no cases of partial or complete flap loss. No acute or chronic complications were noted. Only one patient required reoperation for thinning of the flap to allow proper shoe fitting. All patients had good functional outcomes and the contractures were fully released. Joint function was regained in all patients except one that required wrist fusion. When indicated, the free perforator ALT flap is an excellent option for challenging reconstructions.
Article
Many diseases and conditions such as hypertrophic scarring require long-term maintenance over the healing cycle to achieve full recovery. However, there is a lack of wound dressings that can sustain over 90 days of therapeutic release. Inspired by the enhancement of wound healing by the nanofibrous morphology and diverse structures of electrospinning, we report an evaporation-based co-axial electrospun fibrous scaffold incorporating polymer brush gatekept nanocarriers for sustained delivery of therapeutics. The release rates of the system were demonstrated to be tunable through polymer graft length, while the system experienced minimal burst release when submerged under aqueous conditions. As a proof-of-concept, we target hypertrophic scarring by loading the system with doxorubicin, which led to inhibition of fibroblast activity without interfering with cell adhesion. Application of our scaffolds on rabbit ear hypertrophic scar models displayed that our scaffolds effectively reduced collagen density and scar-related gene expression in healing tissues, with improved tissue elevation outcomes. We envision that our long-term release scaffolds will be useful in combating long unresolved clinical dilemma such as tendon adhesion and tumor regression.
Article
Contractures can complicate burn recovery. There are limited studies examining the prevalence of contractures following burns in pediatrics. This study investigates contracture outcomes by location, injury, severity, length of stay, and developmental stage. Data were obtained from the Burn Model System between 1994 and 2003. All patients younger than the age of 18 with at least one joint contracture at hospital discharge were included. Sixteen areas of impaired movement from the shoulder, elbow, wrist, hand, hip, knee, and ankle joints were examined. Analysis of variance was used to assess the association between contracture severity, burn size, and length of stay. Age groupings were evaluated for developmental patterns. A P value of less than .05 was considered statistically significant. Data from 225 patients yielded 1597 contractures (758 in the hand) with a mean of 7.1 contractures (median 4) per patient. Mean contracture severity ranged from 17% (elbow extension) to 41% (ankle plantarflexion) loss of movement. Statistically significant associations were found between active range of motion loss and burn size, length of stay, and age groupings. The data illustrate quantitative assessment of burn contractures in pediatric patients at discharge in a multicenter database. Size of injury correlates with range of motion loss for many joint motions, reflecting the anticipated morbidity of contracture for pediatric burn survivors. These results serve as a potential reference for range of motion outcomes in the pediatric burn population, which could serve as a comparison for local practices, quality improvement measures, and future research.
Chapter
The chances of survival after a major burn injury have constantly increased over the past decades and further decreases in mortality rates seem to be out of reach [1]. Recent data shows that 96.8% of all patients treated in a US burn center survive [2]. However, many survivors suffer from disfiguring scarring, life-long physical disabilities, and adjustment difficulties. Focus has shifted more and more attempts to improve long-term outcomes with recent advances in discovering underlying mechanisms, treatment of scars, and early rehabilitation.
Article
Introduction This study determined the degree of ROM limitations of extremities, joints and planes of motion and their prevalence over time after burns. Method For this study the database of a longitudinal multicenter cohort study in the Netherlands (2011–2012) was used. From patients with acute burns that involved joints of the neck, shoulder, elbow, wrist, hip, knee and ankle and had surgery (17 planes of motion) ROM was assessed by goniometry at the following timepoints: 3, 6 weeks, 3 months and subsequently every 3 months up to 12 months after burns and at discharge. Results Of 1720 limited planes of motion measured during recovery (117 patients, 353 joints), 1359 (80%) had a minor or mild severity rating; most planes of motion were limited less than 50% of full ROM. The most severely limited planes of motion at 12 months were neck extension (51%) and ankle dorsal flexion (44%). Five planes of motion were unlimited, all of the lower extremity. Conclusion Degree of ROM limitations and prevalence varied over time between extremities, joints and planes of motion. The degree of ROM limitations in the early phase and at discharge was not predictive for degree of ROM limitation in the long term.
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Traditionally, burn rehabilitation is performed in person with hands-on utilization of burn care interventions. The evolution of technology has provided burn clinicians alternative platforms to conduct high-quality burn care resulting in positive patient outcomes, versatile visit format in parallel with in-person care, and high patient satisfaction. Similar to in-person visits, telerehabilitation contains three parts: before the visit, during the visit, and after the visit, which include screening patient appropriateness; assuring readiness of patient and burn clinician to use virtual platforms, evaluation, assessment, and implementation of burn care interventions; and thorough documentation of patient status, limitations/barriers, and patient gains. As the teleburn rehabilitation service delivery model continues to rapidly evolve, further studies into clinician competence and feasibility, impact studies on health-related quality of life, and development of virtual measurement tools and burn care practice guidelines are needed.
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Kinesiophobia, the fear of movement and re-injury, has not been described in burn injury survivors. Physical activity is a key component of burn rehabilitation programs. Yet, not all burn survivors exercise at the recommended level. This is an exploratory study examining the association of the demographics and injury characteristics of burn survivors with a fear of movement. The subjective fear of movement was measured using the Tampa Scale for Kinesiophobia (TSK). The TSK score was compared between several demographics and injury characteristics by performing the independent sample t-test. Sixty-six percent of subjects in our study (n=35), reported high levels of kinesiophobia (score 37 or above). The mean scores of the TSK were greater in males (40.7), non-White (43.0), Hispanic/Latino (41.1), age greater than 50 years (42.3), and total body surface area (TBSA) burn of >15% compared to females (36.9), White (38.5), non-Hispanic/Latino (39.3), age 50 years or less (38.1), and TBSA 15% or less (39.4) respectively. However, with the exception of time post injury, none of the mean differences were statistically significant. Subjects who had sustained a burn injury more than 12 months ago showed higher levels of kinesiophobia than the subjects who were injured within 12 months with a mean difference of 7.35 (p=.01). Thus, this study highlights the importance of (i) continued, long-term follow up for burn survivors, and (ii) appropriate educational and treatment interventions to address any underlying existing, new, or emerging medical issues that may contribute to the fear or avoidance of movement.
Article
Background: Scar contracture is a well-known sequela of burns that is specifically relevant as it may limit function. Reports regarding the course of scar contractures, however, are scarce and, moreover, not focussed on function. This study describes the course of prevalence of scar contractures that limit function in children and adolescents after burns. Method: Range of motion (ROM) of extremity joints of 20 children and adolescents after burns were assessed at discharge (T0) and at six weeks (T1), three months (T2), and six months (T3) after discharge. A scar contracture limiting function was defined as a measured ROM lower than the functional ROM, i.e., ROM used to perform daily activities by unimpaired subjects. Results: At discharge (T0), 89.5% of the subjects had one or more scar contractures that limited function. Six months later (T3), this prevalence was 76.5%. At discharge (T0), less function limiting scar contractures were found for the upper extremity (29.7%) than the lower extremity (53.3%). Over time, prevalence of contractures in both extremities fluctuated between 22% and 35%. Conclusions: The majority of children and adolescents (13/17) still had scar contractures limiting function six months after discharge (T3). Substantial longitudinal studies over a longer period of time are needed to increase our knowledge on the course of these scar contractures in order to support improvements in burn care. Trial registration: The study is approved by the Regional Committee for Patient-Oriented Research Leeuwarden in the Netherlands (NL45917.099.13).
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Over the past 20 years, there has been remarkable improvement in the chances of survival of patients treated in burn centers. A simple, accurate system for objectively estimating the probability of death would be useful in counseling patients and making medical decisions. We conducted a retrospective review of all 1665 patients with acute burn injuries admitted from 1990 to 1994 to Massachusetts General Hospital and the Shriners Burns Institute in Boston. Using logistic-regression analysis, we developed probability estimates for the prediction of mortality based on a minimal set of well-defined variables. The resulting mortality formula was used to determine whether changes in mortality have occurred since 1984, and it was tested prospectively on all 530 patients with acute burn injuries admitted in 1995 or 1996. Of the 1665 patients (mean [+/-SD] age, 21+/-20 years; mean burn size, 14+/-20 percent of body-surface area), 1598 (96 percent) lived to discharge. The mean length of stay was 21+/-29 days. Three risk factors for death were identified: age greater than 60 years, more than 40 percent of body-surface area burned, and inhalation injury. The mortality formula we developed predicts 0.3 percent, 3 percent, 33 percent, or approximately 90 percent mortality, depending on whether zero, one, two, or three risk factors are present. The results of the prospective test of the formula were similar. A large increase in the proportion of patients who chose not to be resuscitated complicated comparisons of mortality over time. The probability of mortality after burns is low and can be predicted soon after injury on the basis of simple, objective clinical criteria.
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Integra dermal regeneration template (Integra Life Sciences, Plainsboro, N.J.) is an effective treatment for full-thickness burns. It can also be useful in contracture release procedures; however, the clinical utility of a dermal regeneration template in contracture release procedures has not been adequately characterized. In this multicenter investigation, the outcomes of release procedures incorporating a dermal regeneration template for 89 consecutive patients, who underwent a total of 127 contracture releases, were retrospectively evaluated. The procedures involved the application of Integra, which includes a temporary silicone epidermal substitute and an artificial dermal layer. After formation of a neodermis, the silicone layer is removed and replaced with an epidermal autograft. Data on patient and contracture site history, treatment methods, physician assessments of range of motion or function, patient satisfaction, recurrence, and adverse events were collected with a standardized questionnaire. Release procedures for the study patients involved the neck, axilla, trunk, elbow, knee, hand, and other anatomical sites. The mean postoperative follow-up period was 11.4 months. At 76 percent of the release sites, range of motion or function was rated as good (significant improvement in range of motion or function) or excellent (maximal range of motion or function possible) by physicians. Responding patients expressed satisfaction with the overall results of treatment at 82 percent of the sites. No recurrence of contracture at 75 percent of the sites was observed during follow-up monitoring. Patient age and prior surgical treatment at the site did not significantly affect the results of treatment. However, outcomes were superior at mature sites, i.e., those for which more than 12 months had elapsed since the original injury. Postoperative complications rarely necessitated regrafting. These results indicate that a dermal regeneration template provides a useful alternative technique for contracture release procedures. The study data indicate that this approach leads to favorable functional outcomes and a high rate of patient satisfaction. This modality also seems to be versatile, because a range of anatomical sites are amenable to treatment with a dermal regeneration template, regardless of prior surgical treatment, and both pediatric and adult patients respond well to this form of therapy. Furthermore, Integra confers functional and cosmetic benefits similar to those of full-thickness grafts but without comparable potential for donor-site morbidity.
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Eighteen patients with burns contracture to the knee 7 (34%), elbow 5 (28%), perineum 4 (22%), and axilla 2 (11%), were treated at our unit between February 1998 to October 2001 using the seven flap-plasty. We chose this method because of its suitability for such contractures, which take the form of a web rather than a straight or linear pattern. Because it involves no donor area, that is no donor site morbidity and therefore less chance for longer hospital stay. The majority of these patients were children 11 (61%). Ten were females (56%) and 8 (44%) were males. Age of patients ranged between 2 and 35 years. The results of the procedure were satisfactory in all patients with good functional recovery of the affected sites.
Article
Rehabilitation medicine has a clear but complex mission. As the 13th century physician-philosopher Maimonides once remarked, "To sustain and nurture a man alive in the throes of disease and disability is as great a miracle as to create him." This credo, emblematic of physiatry's calling, is well represented in the pages of Dr Randall L. Braddom's new rehabilitation textbook, Physical Medicine and Rehabilitation.Intended as a revitalized rendition of an earlier classical rehabilitation text, Krusen's Handbook of Physical Medicine and Rehabilitation, this volume aims to expand and modernize its coverage of PM&R. The goal of Physical Medicine and Rehabilitation, according to its editor, is to "meet the needs of the modern practitioner." By providing state-of-the art information, this volume is a nice complement to its legendary predecessor. As one of several formidable physiatry textbooks that have become available in recent years, Braddom's Physical Medicine and Rehabilitation is likely to appeal
Article
Since physical movement stimulates inflammation, which delays scar maturation, local immobilization is important for early reduction of inflammation. Conventional splint and corset devices often are not adequate in reducing scars to a smooth surface. A new sponge fixation method, using a self-adhesive splint (Fixton), is especially designed for use in extension, traction, and immobilization of skin and soft tissues. It can be applied to any part of the body surface, including functional and moving parts. A case report describes success with the use of the adhesive splint in reducing buckling and contracture in the neck area to a smooth skin surface in a 39-year-old patient. (C)1984The American Burn Association
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Two hundred patients with neck burns were analyzed to determine the incidence of contractures. It was found that only 8 per cent of patients with second degree burns had contractures, all of which were mild. Both the overall incidence of cervical contractures in patients with third degree neck burns and their severity can be decreased by the use of a custom-formed isoprene splint. Splinting should begin as soon as possible after the burn and continue until scar maturation is complete.
Article
Serial casting is a fast, relatively simple, and inexpensive way to effectively correct burn scar contractures. Plaster casts provide circumferential pressure and a prolonged stretch to contracted tissue and cannot be removed by the patient. When casts are applied well and padded appropriately, there is little risk of pressure areas, since the casts are conforming and do not slip distally. Serial casting may be a successful alternative when low-force dynamic splinting cannot be sized small enough for a child, or when patient compliance is unreliable. A case study of a 2-year-old male patient with severe plantar-flexion contractures of the ankles is presented.
Article
Twenty-eight examples of postburn contracture of the neck managed during the last 5 years gave us a better understanding of the problems of anaesthesia, contracture release, skin grafting, splintage and maintenance of the fully release state. The severe contracture should be incised before intubation under a local anaesthetic agent. The release should include the adjoining contractures of mandibular and pectoral regions lest the skin graft is pulled by the existing contracture. Haemostasis should be meticulously secured to avoid graft loss. Splintage should be a static splint for 4-6 weeks followed by a dynamic splint until the applied graft becomes soft, supple and wrinkle free. Ideally, however, contractures should be prevented by nursing the patient with a neck extension in the acute phase and wearing a cervical collar during the subacute phase of wound healing.
Article
Since the use of fire became part of life, mankind has sought remedies to treat burns. The upper extremity, due to its frequency of exposure as the foremost organ in the everyday exploration of the environment and in manipulative and social interactions, is often involved. This article discusses the history of burn treatment.
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The purpose of this study was to assess the effectiveness of serial casting of burn contractures that were resistant to traditional methods of treatment such as paraffin therapy, massage, exercise, and splinting. Serial casting was used to increase the range of motion in 35 joints in 15 patients with burns. A mean increase of 54% was achieved. Casting provided immediate results with minimal complications and was accepted well by patients. Casts were easy to apply and effective even with noncompliant patients. They also delayed or eliminated the need for surgical correction.
Article
We describe an easily constructed bed device for maintaining proper upper extremity position of the burn patient. The device maintains proper arm position while the patient is supine or upright in bed.
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An important element in the care of the burn victim is the prevention and treatment of burn wound contractures. Since limited objective quantitative information is available on the incidence of contractures after thermal injury, or on the factors that predispose individuals to their development, a review of all patients seen from July 1980 through January 1986 for surgical correction of burn wound contractures was conducted. Among the 53 patients selected for study, the incidence of contractures was higher in the pediatric patients, 7.8%, than in the adult patients, 2.0% (P less than 0.001), although burn wound size was comparable in these two groups. There was a direct relationship between wound size and number of contractures per patient (P = 0.003). The majority of contractures occurred at the hand, head, neck, and axilla. Surgical release of contractures of these central body regions (P = 0.056) and of fascially excised burns (P = 0.04), yielded the poorest operative results. Patient age and race, type of operation performed, and timing of surgery did not affect the operative results.
Article
The effectiveness of a silicone gel sheet in increasing active range of motion (ROM) over burn wound contractures of the elbow and axilla was investigated. Gains in motion resulting from use of the gel sheet in conjunction with standard exercise and activity were measured and analyzed. These gains were also contrasted with gains in motion achieved over contralateral anatomical sites with the use of exercise alone. After 10 minutes of gel sheet application there was a mean +/- SD gain of 11.6 +/- 7.8 degrees of extension or abduction, whereas the contralateral control sites gained a mean +/- SD of 1.0 +/-2.7 degrees. It was concluded that use of the silicone gel sheet and exercise resulted in significantly greater gains in active ROM over burn wound contractures than did the use of exercise alone. (C)1985The American Burn Association
Article
A new method of treatment for burn scar management is outlined using silicone gel sheets (Spenco Corporation MD-3071). The method has been applied to 42 patients with burns of varying degree and maturity. The results have been successful in all cases. The mode of action of the gel is unknown, but it does not rely on pressure. The method can easily be tailored to the individual needs of the scar and the patient. Individual initiative and a flexible approach to its use are advocated.
Article
Coincident with the recent development of more effective acute care of burn injured patients, has been the growth of dynamic, integrated rehabilitative efforts. The physical, emotional, and social problems that face the thermally injured patient must be solved in a constructive, coordinated manner within the matrix of total patient care. Most burns are minor burns, which may be optimally treated on an outpatient basis in a physical medicine department. Hospitalized patients, with more extensive and severe burns, should have the benefit of rehabilitative team efforts immediately after injury. We describe a comprehensive approach to the rehabilitative care of the thermally injured, including the techniques of wound management, positioning, splinting, and exercise at all chronologic phases of care. The psychosocial component of patient care is also discussed and the importance of counseling and relaxation methods addressed. Specialized problems and therapeutic techniques associated with hand burns are explained and appropriate splinting methods are illustrated.
Article
Severe contractures that develop early following a burn may not improve with splinting and exercise treatment. An alternative treatment is serial casting, which has been used to promote increased range of motion, to facilitate patient compliance with positioning, and to prevent the patient from scratching the burned area. This case report describes the use of serial casting for resolution of ankle plantar-flexion contractures that occurred in the acute phase of burn injury. The child described in this case report sustained a 49% total body surface area scald burn and developed contractures within 1 week after injury. The contractures, which were not corrected with thermoplastic splints, improved with casting from 45 degrees of plantar flexion to neutral dorsiflexion over 2 months with biweekly cast changes. The patient had multiple skin grafts and progressed in functional activities. Serial casting is a conservative and effective modality in correcting contractures resulting from burns. Further documentation of the efficacy of this treatment approach is necessary to support its use in burn care throughout various stages of healing.
Article
This study compared results of patients who received standard burn physical therapy and topical ultrasound with patients who received standard care alone to investigate the effect of topical therapeutic ultrasound on range of motion and pain in patients with burns. Fourteen burned extremities were studied. Eight joints were randomized to treatment with ultrasound followed by 10 minutes of passive stretching. Six joints received placebo ultrasound treatments and stretching. All treatments were performed every other day throughout a 2-week study period. Joint range of motion was measured before and after each treatment, and patients estimated the pain of the procedure. Patients and therapists were blinded to the treatment group. Analysis of the data revealed no differences in range of motion or perceived pain between the two groups. The effect of ultrasound on range of motion and pain was not predictable. We conclude that patients are not likely to improve from ultrasound treatment at our protocol parameters.
Article
Any soft-tissue deficiency about the axilla unfortunately may readily be translated into a functional limitation of the upper extremity that should be addressed in a simple yet expeditious fashion. Commonly a sequela of burn injuries, significant skin destruction in kind must be restored. Whatever the etiology of major deformities, the vital axillary structures and preservation of shoulder range of motion may best be accomplished by resurfacing with the use of vascularized tissues taken from sources adjacent to the defect. If this is the case, the efficacious application of these local muscle or fascial flaps mandates a realization that such choices are finite in number. A schema for a reasonable flap selection process has been devised based on the relative severity and anatomic location of the axillary burn scar contracture.
Article
In spite of the common teaching that contracture releases should be avoided until scars have matured, the Cincinnati Shriners Burns Institute has been releasing contractures in immature scars to prevent prolonged loss of range of motion. To evaluate the efficacy of axillary releases and, especially, to determine whether releases performed in immature scars were detrimental, axillary releases that were performed between January 1, 1988 and December 31, 1989 were evaluated for improvements in abduction and flexion. Overall, axillary releases significantly improved abduction and flexion, and the improvement was maintained for at least 1 year. Comparison of early (less than 1 year after burn injury) with late (more than 1 year after burn injury) releases revealed that the preoperative limitation was worse in the early release group but that the ultimate outcomes were similar. Waiting for scars to mature before performance of contracture releases is not necessary.
Article
The purposes of this study were to document (1) the historical use of splints, (2) record the current practice of splint application, and (3) compare splint philosophy of the past with present practice. One hundred burn references were reviewed for information on the past use of splints. Present practice was determined on the basis of a survey of 99 burn centers. Information is presented as to when splints are applied to burn patients in their course of recovery for 12 body areas prone to scar contracture. The influence of burn depth is noted. A change in the practice of applying splints to burn patients appears to have occurred. Part I of this series describes the global results and details whether splints are necessary.
Article
Approximately 100 therapists attended the PT/OT Casting Workshop at the twenty-ninth Annual Meeting of the American Burn Association in New York City, N.Y., on March 20, 1997. The workshop consisted of four groups: two demonstrating hand/wrist casting and two demonstrating casting of the foot/ankle. Participants had the opportunity to attend one upper extremity group and one lower extremity group lasting approximately 50 minutes each. Instructors provided a demonstration of a casting procedure while addressing general guidelines, indications, contraindications, and precautions related to casting each area. Thorough handouts were provided, and each participant had the opportunity to apply two casts. The following article is a compilation of the four handouts and their bibliographies.
Article
A case of severe post burns contracture of the wrist, of 43 years duration resulting in recurrent ulceration of the skin was successfully treated by gradual distraction using the Ilizarov method. This method is superior to plaster of Paris cast and is more versatile than other forms of external fixation.
Article
Postburn scarring and contracture affecting function remain the most frustrating late complications of burn injury. Various techniques are used to release contractures; the choice depends on their location and/or the availability of unaffected skin adjacent to the contracture or elsewhere. A retrospective review was carried out of the case notes of patients who had skin grafting for the release of postburn contracture at the Burns Unit, City Hospital, Nottingham between May of 1984 and August of 1994 to evaluate the experience over this period. Information was obtained about the burn injury, contracture site, interval between burn and release of contracture, indication, age at first release, intervals between releases, operative details (donor and graft sites), complications and nonoperative treatment, and follow-up to the end of the study period. A total of 129 patients underwent skin grafting for release of contractures as opposed to any other method of correction. Full-thickness skin grafts were used in 81 patients (63 percent) and split-thickness skin grafts in 26 (20 percent). Twenty-two patients (17 percent) had both types used on different occasions. Flame burns (41 percent) were the most common causes, followed by scalds (38 percent). Two hundred thirty-nine sites of contracture were released, with the axilla (59) and the hand/wrist (59) being the most common sites involved, followed by the head/neck region (42). It was found that for the same site, release with split-thickness skin grafts was associated with more rereleases of the contracture than with full-thickness skin grafts. Also, the interval between the initial release and first rerelease was shorter than with full-thickness skin grafts (p < 0.048). It was also noted that children required more procedures during growth spurts, reflecting the differential effect of the growth of normal skin and contracture tissue. Patients reported more satisfaction with texture and color match with the full-thickness skin grafts. There was comparable donor-site and graft morbidity with both graft types. The use of skin grafts is simple, reliable, and safe. Whenever possible, the authors recommend the use of full-thickness skin grafts in preference to split-thickness skin grafts in postburn contracture release.
Article
Neck and axillary burn contractures are both a devastating functional and cosmetic deformity for patients and a challenging problem for reconstructive surgeons. Severe contractures are more commonly seen in the developing world, a result of both the widespread use of open fires and the inadequacy of primary and secondary burn care in these vicinities. When deep burns are allowed to heal spontaneously, patients develop hypertrophic scarring of the neck and axillary areas. The back is typically spared, however, remaining a suitable donor site. We have used nine latissimus dorsi myocutaneous flaps in a total of six patients, finding the flaps effective in resurfacing both the neck and the axillary regions after wide release of burn contractures. Before flap mobilization, surgical neck release is often necessary to ensure safe, effective control of the airway in patients with significant neck contractures. Flap bulkiness in the anterior neck region can eventually be reduced by dividing the thoracodorsal nerve. Anchoring the skin paddle to its recipient site through the placement of tacking sutures will also help achieve a more normal anterior neck contour.
Article
Dynamic splinting for the burned hand is used worldwide. We previously presented a home hand therapy program. This program included a series of dynamic splints made by the occupational therapist for daily use by the patient. The "supersplint" evolved from the need to reduce the time required to manufacture the splints for the home therapy program; it also reduced patient-therapist sessions in the occupational therapy unit. The supersplint provides active-resistive movements of the fingers and thumb. As range of motion progresses, resistance can be increased to strengthen muscles and tendons. The supersplint provides tendon gliding, helps control edema, prevents muscle disuse, prevents skin and capsular contracture, minimizes complications, and helps prevent deformities. The patient uses the supersplint daily as part of an occupational therapy program that includes activities of daily living, prevention of shoulder hand syndrome, and scar therapy (including pressure garments).
Article
The treatment of burn scar contractures is a major emphasis in the rehabilitation of patients with burn injuries. Many treatment techniques have been used successfully but without a critical investigation of the best practice of care. In this study, we compared the outcomes for pediatric and adult patients treated with a multimodal therapy approach to treatment techniques that are considered to be progressive to determine if differences existed in the techniques. The medical records of 52 patients with documented burn scar contractures were reviewed for patient and rehabilitation treatment parameters. Included were population demographic information and type of treatment intervention used to correct the scar contracture. In particular, the postburn day when the contracture appeared, the percentage of range of motion deficit, the day when definitive treatment that eventually corrected the contracture was begun, and the days required to correct the contracture were noted. With equal range-of-motion deficits identified, the burn scar contractures of patients in the progressive treatment group were corrected in less than half the time of the burn scar contractures of the patients in the multimodal treatment group. This result occurred despite scar contractures that appeared significantly earlier and later initiation of definitive treatment.
Article
Successful treatment of dorsal foot burns is a challenge. By extrapolating from various treatments of dorsal hand burns the design of a static progressive splint was applied to the treatment of dorsal foot burns to prevent contracture deformities. The splint is composed of a base, dorsal thermoplastic piece, and Velcro strap. Soft hook and loop Velcro encircles the ankle and midfoot providing a base for the attachment of a Velcro strap. A thermoplastic piece is conformed to the dorsum of the toes and then affixed to the Velcro strap. The Velcro strap is then attached to the plantar surface of the base to create an adjustable static progressive stretch. This splint is designed to prevent dorsal foot contractures during the scar maturation phase of wound healing.
Article
Inappropriate treatment of axillary burns frequently results in adduction contractures. In this clinical study we have reviewed 32 patients with different types of axillary post-burn adduction contractures. We have used a variety of surgical treatments for reconstruction of axillary contracture releasing defects such as simple grafting, Z-plasties and locally pedicled flaps. Among these alternatives, we preferred to use scapular island flap most frequently. In addition to conventional harvest of this flap, extension of its pedicle up to the subscapular ramification by passing it through the triangular space allowed its transfer even to the anterior axillary line defects in a vertical orientation without pedicle kinking. In conclusion, the island scapular flap is a good choice for reconstruction of all types of axillary contracture, releasing defects with satisfactory results in terms of function and cosmesis.
Article
Continuous body growth and rigidity of scars in children are significant contributors to burn scar contractures (BSCs). BSCs decrease a patient's range of motion and their ability to perform activities of daily living. A benefit of exercise is an increase the patient's ability to perform and sustain activities of daily living. Therefore, we investigated whether patients who were involved in a supervised, hospital-based exercise program, in addition to physical and occupational therapy (PTEX), would have fewer surgical interventions than a nonexercise group receiving home-delivered physical and occupational therapy (PT) alone. We examined 53 patients at 6, 9, 12, 18, and 24 months postburn. The PTEX group (n = 27) completed a 12-week supervised exercise program starting at 6 months postburn. Exercise sessions were held three times per week, with duration of 60 to 90 minutes per session. Resistance and aerobic exercises were performed at 70 to 85% of the patient's maximal effort. In contrast, the PT group (n = 26) received a home rehabilitation program with no supervised exercise. Patients were evaluated at 3-month intervals for scar formation, range of motion, and need for surgery. At 12, 18, 24 months postburn, the number of patients in the PTEX group needing release of BSC was significantly lower than the number of patients in the PT group. The results indicate that patients would receive a significant benefit if enrolled in a supervised exercise and physiotherapy program with the exercise portion consisting of an aerobic and resistance-training component. This type of program is beneficial in decreasing the number of surgical interventions and should be incorporated as part of a postburn outpatient rehabilitation.
Article
This report present an evaluation 13 consecutive cases of severe burn scar contracture of the axilla and investigates the factors that influence functional improvement. The operation was performed at various times during the period from 3 months to 63 years after the initial burn wound healed. The active range of shoulder abduction before the operation in these patients was restricted to 30-90 degrees. The scar contractures in the axilla were released in all cases and the defects of the axillary region were covered with musculocutaneous flaps or fasciocutaneous flaps. Following operation rehabilitation was performed with the range of shoulder abduction had reached a plateau. The relations between the improved range of shoulder abduction, time to reach a stable range of abduction, patient age and duration of illness in each patient are discussed. Patient with long post-injury periods required a longer time to reach a stable range of abduction. Furthermore, the patients with an extremely long period before operation had difficulties such as nerve injury or stiff joint which restricted improvement. In conclusion, adequate surgical treatment in early period after occurrence of contracture is desirable for burn scar contracture of the axilla.
Article
Children with axillary burns often develop scar contractures that restrict shoulder movement. Objective data on functional movement patterns after contracture formation is sparse. The purpose of this study was to determine how axillary contractures affect shoulder movement during activities of daily living (ADLs). This was a prospective study of children with axillary contractures scheduled for surgical release. Three-dimensional upper extremity kinematic analysis was used to assess shoulder, elbow, and trunk motion during two ADLs: high reach and hand to back pocket. Results were compared with a pool of 49 normal age-matched controls. Eleven children with axillary contractures were compared with controls. During high reach, significant decreases in shoulder flexion, shoulder internal rotation, arm pronation, and trunk extension occurred. Elbow flexion increased significantly. In the hand to back pocket task, shoulder extension and elbow flexion decreased and shoulder abduction increased. Axillary contractures result in quantifiable movement changes during ADLs. Aggressive rehabilitation is required to prevent contracture formation. Three-dimensional motion analysis is a unique tool for the quantification of functional limitations and provides an objective method to evaluate treatment efficacy in patients with axillary contractures.
Article
External splinting has been acknowledged for many years as a useful approach for preventing and correcting burn contractures. Though this practice could be traced back many centuries, there is still a dearth of knowledge regarding a good splint to serve these purposes for axillary burns. The newly designed multi-purpose, self-adjustable aeroplane splint presented in this report helps in various ways, such as improving compliance, and positioning during preoperative, postoperative and rehabilitative phases of axillary burn management. It acts as a splint that provides circumferential pressure for scar management, provides prolonged stretch to contracted tissue and acts as a serial cast in increasing the shoulder range. Most of all, it is very much user-friendly, thus enhancing compliance and giving a good outcome in axillary burns.
Article
Significant neck burns may lead to deforming lateral flexion and rotation contractures. A two-device splinting regimen has been designed to prevent such contractures. In the acute phase, the Dynamic Antitorticollis Strap is applied while the patient is in bed to gently rotate the head and neck toward the neutral position. This dynamic strap includes a Velfoam headband attached to Thera-Band secured to the patient's bed. The antitorticollis neck splint is used in the rehabilitation phase and can be serially adjusted to correct lateral flexion contractures of the neck. Thermoplastic material is cut from a modified neck splint pattern and draped over the temporaloccipital region and anterior/posterior shoulder ipsilateral to the contracture and the anterior and contralateral aspect of the neck. The combined use of these devices during the scar maturation phase provides therapists with alternatives in preventing burn scar torticollis.
Article
To investigate the efficacy and versatility of subcutaneous pedicle rhomboid flap in the treatment of linear or wide postburn scar contractures located in various parts of the body. Twenty-three patients (aged 5 to 35 years) with postburn linear and wide scar contractures were treated with 31 subcutaneous pedicle rhomboid flaps. Rhomboid flaps were applied in the trunk (4 flaps), head and neck (5 flaps), lower extremity (5 flaps), and upper extremity (17 flaps). In 3 cases, Z-plasty was incorporated to the technique due to inadequate release. All rhomboid flaps healed uneventfully. In 28 contractures, rhomboid flaps alone were efficient to release the tension line (90.3%). Tip necrosis of the triangular flaps of Z-plasty in 1 case was the only complication seen that later led to recontracture. Clinical results indicated that subcutaneous pedicle rhomboid flap is a simple, efficient, and versatile technique in release of any postburn scar contracture. As no undermining is carried out, the flaps are more reliable than commonly used Z-plasty. Again contrary to Z-plasty, displacement of anatomic landmarks such as axillary hair and areola is rare with the technique.
The relationship between upper extremity contractures and functional outcome after burn injury (abstr)
  • Kj Kowalske
  • Jr Voege
  • Cromes
  • Jr
Kowalske KJ, Voege JR, Cromes GF Jr., et al. The relationship between upper extremity contractures and functional outcome after burn injury (abstr). Proc Am Burn Assoc 1996; 28:55.
The effect of potassium iodide iontophoresis on range of motion and scar maturation following burn injury
  • Jb Driscoll
  • K Plunkett
  • Tamari
Driscoll JB, Plunkett K, Tamari A. The effect of potassium iodide iontophoresis on range of motion and scar maturation following burn injury. Phys Ther Case Rep 1999;2:13–8.