Department of Plastic, Hand, Reconstructive Microsurgery and Burns Surgery, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, Tamil Nadu, India

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1 Free full text on Review Article DOI: DOI: / Mngement of post urn hnd deformities S. Rj Spthy, Bu Bjntri, R. Rvindr Bhrthi Deprtment of Plstic, Hnd, Reconstructive Microsurgery nd Burns Surgery, Gng Hospitl, 313, Mettuplym Rod, Coimtore, Tmil Ndu, Indi Address for correspondence: Dr. Rj Spthy S, Deprtment of Plstic, Hnd, Reconstructive Microsurgery nd Burns Surgery, Gng Hospitl, 313, Mettuplym Rod, Coimtore, Tmil Ndu, Indi. E-mil: ABSTRACT The hnd is rnked mong the three most frequent sites of urns scr contrcture deformity. One of the mjor determinnts of the qulity of life in urns survivors is the functionlity of the hnds. Burns deformities, lthough lrgely preventle, nevertheless do occur when pproprite tretment is not provided in the cute sitution or when they re prt of mjor urns. Reconstructive procedures cn gretly improve the function of the hnds. Approprite choice of procedures nd timing of surgery followed y supervised physiotherpy cn e oon for urns survivor. KEY WORDS Posturn hnd deformity; contrcture relese; hnd urns INTRODUCTION One of the mjor determinnts of the qulity of life in urns survivors is the functionlity of the hnds. Posturn hnd deformities, if ilterl, cn mke urn survivor totl cripple [Figure 1]. The prolem is lrgely preventle y good initil cre, which would include elevtion of the hnd, pproprite splinting, erly grfting of deep urns nd supervised physiotherpy. Tredget [1] found tht in ptients with men totl ody surfce re urn of 15%, 54% of the ptients sustined urns to the hnd nd upper extremity. Becuse of the high frequency of occurrence of hnd urns, the chnces of the occurrence of deformity is high. The hnd is rnked s one of the three most frequent sites of urn scr contrcture deformity. [2] In this rticle, we hve first explined the generl principles tht were found useful in treting urn hnd deformities, followed y technicl spects pertining to commonly seen deformities. GENERAL PRINCIPLES IN THE MANAGEMENT OF POSTBURN HAND DEFORMITIES 1. While reconstructing urnt hnd, the urn surgeon must concentrte on restoring function thn just Figure 1: Severe urn contrctures of oth hnds mking this urn survivor totl cripple S72

2 on incresing the rnge of movement of individul joints. Surgery on the urnt hnd must restore pinch, the ility to grsp lrge ojects nd the power grip. This is otined when the thum pulp meets the pulp of other fingers, the hnd hs dequte first we spce nd the musculo tendinous units function to provide dequte power. Surgicl procedures must e chosen to chieve these rther thn iming for n increse in the rnge of movement in ech individul joint. For exmple, it might e n dvntge to hve PIP joint rthrodesed in good functionl position thn to perform complicted procedures to restore movement in d outonniere deformity. 2. When hnd is severely involved, choose the first set of procedures tht will ring the mximum enefit to the ptient. It is usul for severe urn contrcture to undergo series of procedures to otin the ultimte functionl result, ut the first procedure must produce perceivle improvement in function. Erly restortion of independence in the use of the hnd will oost the morle nd encourge the ptient to dhere to postopertive protocols nd tke up susequent procedures. 3. Function is very importnt, ut urn surgeon must lso constntly think of the esthetic spect of reconstruction of urned hnd. The hnd is prt tht is lwys exposed nd constntly reminds the ptient tht he is different. An estheticlly cceptle reconstruction helps him or her to esily integrte ck into the society. The sttement y Guy Foucher tht hnd surgery is lso esthetic surgery hs never een truer thn in the tretment of urned hnds. [3] 4. Assess the deformity in ech tissue component to mke the tretment pln. Burn deformities occur secondry to skin loss. But, deformity correction involves not only correcting the skin loss ut lso the secondry chnges tht hve occurred in the musculo tendinous units nd joints. They usully re the limiting fctors for deformity correction. Evlute the deformity in ech of the components of skin, tendons, joints nd ones while mking the tretment pln. 5. Correction of the deformity depends on the excision of the scr tissue nd correcting the deforming forces thn on the type of skin cover provided. Most deformity correction would need skin replcement. Mere replcement of the urn scr with skin grft or flp will not correct the urn deformity. 6. Timing of surgery is crucil to get good outcome in deformity correction. It is etter to perform the surgery when there is tissue equilirium, s shown y reduction of the indurtion nd the scrs ecoming ple. 7. Physiotherpy, splinting nd scr control mesures re importnt to chieve good outcome. All these principles will pply to the correction of ny urn deformity in some wy or the other. Burn scr contrctures hve een clssified y Mc Culey [4] [Tle 1]. MANAGEMENT OF INDIVIDUAL DEFORMITIES Dorsl hnd deformities In the clssicl dorsl hnd deformity, there is clwing of the fingers hyperextension of the metcrpophlngel joints nd flexion of the interphlngel joints. [Figure 2]. The severe oedem in the dorsum of the hnd cuses hyperextension of the metcrpophlngel joints. The plmr rches fltten. Flexion of the PIP joint occurs s result of this oedem-imposed tension on the common digitl extensor tendon system nd concurrent hyperextension of the MP joints. The ring nd the little fingers re ffected 65% of the times. [5] With time, the joints ecome stiff nd the extensor tendons undergo dptive shortening. The poor qulity of skin t the PIP joint my expose the tendon nd the extensor my rupture secondry to stretch nd ischemi. Grde I Grde II Grde III Grde IV Tle 1: Clssifiction of urn scr contrcture Symptomtic tightness ut no limittions in rnge of motion, norml rchitecture Mild decrese in rnge of motion without significnt impct on ctivities of dily living, no distortion of norml rchitecture Functionl deficit noted, with erly chnges in norml rchitecture of the hnd Loss of hnd function with significnt distortion of norml rchitecture of the hnd Suset clssifiction for Grde III nd Grde IV contrctures: A: Flexion contrctures, B: Extension contrctures, C: Comintion of flexion nd extension contrctures S73

3 [Downloded free from on Mondy, July 30, 2012, IP: ] Click here to downlod free Android ppliction for this journl c d e f g h i Figure 2: Dorsl urn contrcture (, ). The hnd functionless due to nrrow first-we spce, nd MCP joints stiff in extension with ssocited IP joint deformities (c). MP joints extension contrcture corrected nd flp given long with volr contrcture relese in the fingers. This procedure mkes the hnd functionl (d). Arthrodesis of the IP joints in stges mkes the hnd estheticlly nd functionlly good (e-i) The thum my lie in the plne of the plm with nrrow first we spce. The gol of tretment is to get the fingers stright, the MCP joints flexed nd fcilitte the thum to oppose the tips of the other fingers. If the IP joints hve fixed flexion deformity, they need to e relesed erlier to or long with the correction of the hyperextension deformity of the MCP joints. Otherwise, the fingertips will ury into the plm, functionlly downgrding the hnd. Adequte relese of the IP joints tht cn e mnged with skin grfts is performed if dorsl relese is lso ttempted [Figure 2]. If, fter the correction of the IP flexion deformity, the rw res would need flp, then dorsl relese is not comined. Skin over the MCP nd the IP joints re highly flexile, with reservoirs of skin overlying the joints. It hs een documented tht there is considerle increse in finger length when moving from position of totl finger extension to complete fisting. The fingers do not move like door hinge; rther, the phlnges rticulte round the hed of the ntecedent segment to ccount for the increse in length [Figure 3]. This point hs to e rememered when replcing skin fter dorsl relese. Aprt from skin shortge, two fctors limit relese of the contrcture. One is the joint prolem. The nterior cpsule ecomes stiff nd dherent to the joint surfces, preventing the proximl phlnx to glide volrwrds [Figure 4]. On pressure, the se of the proximl phlnx my tilt upwrds. When this hppens, the cpsule needs to e opened nd, with the help of curved dissector, pocket needs to e creted for the phlnx to glide forwrd. S74

4 thickness of the plmr skin. Deep urns of the plm occur in cmphor urns ssocited with religious prctices, industril ccidents nd in electricl injuries. In the lter two instnces, hnd deformities my e ggrvted y the ssocited comprtment syndrome nd crpl tunnel syndrome. Erly recognition of comprtment syndrome nd crpl tunnel syndrome nd decompression will reduce deformities ssocited with plmr urns. Figure 3: The flexion of the fingers is unlike tht of the door hinge. There is considerle increse in length s the phlnges glide over the proximl ones, which require more skin fter contrcture relese The other fctor is the dptive shortening of the extensor tendons. It is etter to stretch the muscles s much s possile, fix the joint nd further stretch the contrcted muscles y physiotherpy. Cutting the tendon nd putting in tendon grft is not recommended. Excursion of the tendon is dependent on muscle fire length. When the gp is ridged y tendon grft, the muscle remins short nd the length of excursion of the tendon ecomes limited [Figure 5]. Swhney feels tht y stged relese, skin grfting nd rigorous physiotherpy, even very severe contrctures cn e corrected without resorting to flp cover nd tendon grfting. [6] In very severe contrctures, if the ptient cnnot fford the time for multiple procedures, the extensor tendons cn e divided to otin flexion of the fingers. Surprisingly, mny ptients djust without extensor reconstruction. The relese is performed y trnsverse incision plced in such wy tht, fter full relese, the distl flp migrtes nd still covers the MCP joints [Figure 6]. Under the flp, MCP joint cpsulotomy is performed. If the joint hs to e temporrily stilized, the K wires re to e oliquely inserted to void trnsfixing the extensor hood. Skin coverge is dependent on the ed nd grfts re preferred if the ed would ccept grft or flp is given. Skin flps re preferle to muscle or fscil flps with grfts ecuse skin flps llow esy ccess for secondry procedures. Whtever flp is used, the ultimte outcome is dependent on the physiotherpy to mintin the gins of surgery. While it is esier to institute erly physio with free flps, even with pedicled dominl flps s cover, it is possile to institute erly physiotherpy [Figure 7]. Volr deformities Burns to the plm re less frequent when compred with dorsl urns nd, more often, re superficil due to the S75 Estlished plmr contrcture results in nrrowing of the metcrpl rch with the thenr eminence pproching the hypothenr re. This results in hyperextension deformity of the MCP joint of the thum nd flexion t the IP joint. Full relese of plmr contrcture is usully possile nd the rw re is covered y full-thickness or thick splitthickness grfts [Figure 8]. The first metcrpl my need to e fixed in extension till the grfts settle. It is etter to use thick skin grfts in the plm thn flp. The ulkiness of the flp prevents cupping of the plm nd the ility to hold ojects. The ptients feel like they re lredy holding something in their hnd. Flps, if they hve to e used, re to e thin or hve to undergo multiple secondry thinning procedures. Skin grfts, even if they hve to e used in multiple stges, ultimtely provide etter outcome s they help in holding ojects etter. Deformities of the thum The most ovious deformity in the thum ppers t the MCP joint. When there is hyperextension contrcture t the MCP joint, swn neck-type deformity occurs in the thum nd, with flexion contrcture t the MCP joint, outonniere deformity occurs. Both my e ssocited with first-we contrcture. When the deformities re of short durtion nd re due to skin contrcture, relese of the contrctures will correct the prolem. If the deformities re severe, n overll pln hs to e mde nd it is linked with the deformities tht the ptient hs in the other fingers. Adduction contrctures of the firstwe spce cn hve significnt impct on overll hnd function. [7] It might require relese of the origin of the first dorsl interosseous from the first metcrpl nd the dductor origin from the third metcrpl. Firous tissue overlying these muscles must lso e relesed. In ddition to gining duction, the im is to otin certin mount of prontion of the thum so tht t the end of the contrcture relese, the pulp of the thum will fce the pulp of the other fingers. Relese of the skin nd first-we muscles will gin duction, ut prontion will

5 [Downloded free from on Mondy, July 30, 2012, IP: ] Click here to downlod free Android ppliction for this journl Figure 5: () Norml muscle. () Contrcted muscle. (c) When tendon grft (d) is used fter contrcture relese, the muscle fire length remins short nd excursion of the muscle is reduced Figure 4: The nterior cpsule llows the se of the proximl phlnx to glide over the hed of the metcrpl (). During contrcture relese, the dhesions over the hed of the metcrpl () hve to e relesed, otherwise the se will dislocte on ttempting to correct the deformity (c) c c Figure 6: A severe dorsl contrcture () Relesed y trnsverse incision plced proximl to the MCP joint (rrows). () The distl flp slides to cover the MCP joints, enling cpsulotomy to e performed with temporry stilistion of the joints. This comined first-we relese mkes the hnd functionl (c) d Figure 7: Severe dorsl nd first-we contrcture (), corrected y contrcture relese nd dominl flp cover (). At 10 dys, dynmic exercises cn e strted even in the presence of pedicl flps (c, d) S76

6 [Downloded free from on Mondy, July 30, 2012, IP: ] Click here to downlod free Android ppliction for this journl c Figure 8: () Severe plmr contrcture. () After relese (c) Long-term mintennce with full-thickness grfts s cover Figure 9: () Severe first-we contrcture in child corrected with posterior interosseous flp () e otined only when the contrcture t the CMC joint is relesed. This hs to e done voiding injury to the rdil vessels. The rw re fter first-we relese lmost lwys would need flp cover. Posterior interosseous flp is n idel choice if the donor site is ville [Figure 9]. Otherwise, distnt pedicle flp or free flp cn e used. At the sme sitting, the thum cn e rought into functionl position y relese of the contrcture t the MCP joint. If difficult, n rthrodesis of the MCP joint of the thum cn e performed. The level nd the inclintion of one freshening cn e used to position the thum in the most pproprite position. A good nd dequte first-we nd stle MCP joint of the thum will provide functionlly nd estheticlly cceptle thum in most instnces. S77 Swn neck deformities A urn swn neck deformity occurs minly due to three cuses. They re, one: due to rupture of the extensor insertion t the distl interphlngel joint cusing mllet deformity, which, secondrily, cuses swn neck deformity. A second cuse is due to the skin contrcture ecuse of deep urns of the dorsum of the fingers. The third cuse is due to tightening of the intrinsics due to ischemic firosis of the intrinsic muscles secondry to comprtment syndrome in the cute phse. Correction ddressing the prolem cn only e effective if the deformity is not fixed. In cute trum, the swn neck deformity secondry to mllet deformity does not progress to fixed deformity nd, hence, correction of the mllet deformity corrects the swn neck deformity. In urns, most often, the extent of injury lso extends proximlly nd the swn neck deformity quickly ecomes fixed deformity. Swn neck deformity ffects function, nd it needs to e corrected. The choice will depend on the cuse. If it is due to dorsl skin contrcture, relese incisions proximl nd distl to the PIP joint nd grfting will correct the deformity. Similrly, mllet deformity correction will correct it in the erly stges. In ll fixed deformities, the most vile option would e rthrodesis of the PIP joint in the functionl position with incresing flexion from the index (25 30 degrees) to the little (40 50 degrees) fingers.[8] Boutonniere deformity The deformity, chrcterized y flexion t the PIP joint

7 nd hyperextension t the DIP joint, is due to the rupture of the centrl slip insertion t the se of the middle phlnx. Tension ischemi cn result when the injured tendon is compressed etween the eschr nd the hed of the proximl phlnx s the PIP joint is flexed. [9] The deformity could e prevented y splinting the PIP joint in extension in the cute stge. While it is dvisle to encourge erly movement in superficil urns, it is prudent to splint deep urns of the dorsum in the cute sitution. If some movement is desired, it is etter to dvice isolted movement t ech joint seprtely thn composite movement of ll joints, which would put more stress on the injured tendons. In ddition, pressure nd tension on the tendons lso cuses ischemic chnges, promoting rupture of the tendon insertion. Contrry to swn neck deformity, persons with outonniere deformities continue to possess fir mount of function. Surgery is indicted when the skin overlying the PIP joint is open, when there is severe hyperextension of the DIP or the MCP joints. Tendonrelncing procedures re rrely possile in urns ecuse of the poor qulity of the overlying skin, nd rthrodesis is resorted to when there re prolems of opposition to the thum. Burn syndctyly Circumferentil urns of the fingers when llowed to hel without grfting cuse syndctyly. The outcome of seprtion of urns syndctyly depends on the sttus nd the depth of the urns of the other prts of the fingers. Usully, the IP joints re stiff nd there is pucity of skin to mke flps, s is performed in congenitl conditions. Most of the times, longitudinl division hs to e mde nd the rw res hve to e grfted. This is the reson for the incresed incidence of we creep fter urn syndctyly seprtion thn fter congenitl cses. When seprting urn syndctyly, s fr s possile, the est ville skin is used to mke the we flp. Full-thickness skin t the we prevents creep. We contrctures re seprted y using different types of Z plsty or y using the squre flp technique. In urn contrctures, in ddition to deepening the we, firous tissue t the we lso needs to e excised to promote lterl movement (duction nd dduction) of the fingers. Unless tht is done, chnces of recurrence re high. Postopertively, pdded splints re to e worn to prevent recurrence. The urnt little finger The little finger is the most ffected finger in urn deformities. Groenevelt, who performed study on this, feels tht little finger ers the runt of urn trum ecuse it most exposed in the protective posture of the hnd nd, most often, suffers circumferentil urns thn other fingers. [10] The deformity could e comintion of flexion nd rottion due to more loss of skin on the outer spect of the finger. Initil mngement is to relese the flexion nd lterl contrctures nd get it out of the plm. If the finger is totlly uried into the plm nd if the other fingers cn esily e restored to functionl position, even mputtion of the deformed little finger my e n dvntge thn undergoing multistge procedures with residul compromised function. Mngement of digitl losses Digitl mputtion my e n isolted digitl loss like the thum in cse of electricl urns or multiple digitl losses tht occur in mjor urns. When the digitl loss is n isolted one, the most vlule microsurgery procedure is toe trnsfer. [11,12] In lrge totl ody surfce re urns with involvement of the feet nd multiple digitl mputtions, free toe to hnd trnsfers my not e possile. In them, finger lengthening techniques y distrction osteosynthesis re useful. [13] Corticotomy of the shortened digit is performed fter plcement of mini-hoffmn device for susequent distrction. After 2 weeks, erly cllus formtion occurs with immture woven one nd osteoprogenitor cells. Susequent distrction of the heling cllus cn occur followed y 2 4-week period of stilistion to llow the new one to solidify. Distrction lengthening is mostly performed in the thum nd the index to restore pinch. For it to e effective, t lest most of the first metcrpl must e present nd skin coverge of the mputtion stump should e dequte. Trditionl techniques like phlngistion nd osteoplstic thum reconstruction re lso rrely used. [14,15] Physiotherpy nd ftercre of posturn hnd deformities The gins mde y surgery hve to e mintined y properly splinting the relesed joints. If Kirshner wires hve een used to hold the joints in position, they re retined for 3 weeks to enle the grfts or flps to settle. The grfts must e mssged nd custom-mde compression grments worn for 6 months for the grfts nd flps to settle. The scrs hve grter tendency to S78

8 contrct in the erly period, relentlessly cting throughout the dy. Therefore, therpy hs to e performed multiple times dy nd the joints hve to e splinted in etween. Good physiotherpy will mke ll the efforts worthwhile. REFERENCES 1. Tredget E. Mngement of the cutely urned upper extremity. Hnd Clin 2000;16: Schneider JC, Holvnhlli R, Helm P, O Neil C, Goldstein R, Kowlske K. Contrctures in urn injury prt II: investigting joints of the hnd. J Burn Cre Res 2008;29: Germnn G, Philipps K. The Burned Hnd. In: Green DP, editor. Opertive Hnd Surgery 5 th ed. New York: Elsevier; 2005; McCuley RL. Reconstruction of the Peditric urned hnd. Hnd Clin 2000;16: Moore ML, Dewey WS, Richrd RL. Rehilittion of the Burnt Hnd.Hnd Clin 2009;25: Swhney CP. Personl communiction. 7. Asuku ME, McCuley RL, Pizz RC II. Reconstruction of the Burned Hnd. In: McCuley RL, editor. Functionl nd Aesthetic Reconstruction of Burned Ptients. Boc Rton: Tylor nd Frncis; P Smith MA, Spence RJ. Burns of the hnd nd upper lim: review. Burns 1998;24: Misels DO. The middle slip or outonniere deformity in urned hnds. Brit J Plst Surg. 1965;18: Groenevelt F. Some spects of the urned little finger. Brit J Plst Surg 1986;39: Spthy SR. Hnd urns in Principles nd Prctice of Burn cre. Srhi S, editor. Jypee Bro; P Krns YL, Buntic RF. Microsurgicl Reconstruction of the Burned Hnd. Hnd Clin 2009;25l: Winwright D, Prks DH. Finger lengthening of the urned hnd y distrction osteosynthesis. In: McCuley RL, editor. Functionl nd Aesthetic reconstruction of urned ptients. New York: Tylor nd Frncis; p Kurtzmn LC, Stern PJ, Ykuoff KP. Reconstruction of the urnt thum. Hnd Clin 1991;8: My JW Jr, Dneln MB, Toth BA, Wll J. Thum reconstruction in the urnt hnd y dvncement polliciztion of the second ry remnnt. J Hnd Surg 1984;9A: Source of Support: Nil, Conflict of Interest: None declred. S79