Analysis of Upper Extremity Motion in Children After Axillary Burn Scar Contracture Release

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1 Analysis of Upper Extremity Motion in Children After Axillary Burn Scar Contracture Release Mitell Sison-Williamson, MS, Anita Bagley, PhD, Kyria Petuskey, MS, Sally Takashiba, BS, Tina Palmieri, MD Burns to the upper extremity and axilla frequently result in the formation of contractures that can impede shoulder range of motion. The purpose of this study was to determine the long-term effects of upper extremity burn scar contracture release on motion during activities of daily living in the first year postrelease. Upper extremity motion analysis was conducted on children aged 4 to 17 years before and 1, 3, 6, and 12 months after axillary contracture release surgery. Movements were analyzed during three functional tasks including high reach (reaching for an object), hand to head (combing hair), and hand to back pocket (toileting). A total of 23 subjects (34 axillary contractures; mean age 10 3 years; mean TBSA burn 40 6%) completed the study. Preoperatively, decreased shoulder mobility due to axillary contractures resulted in the use of compensatory motions to complete the tested activities. Surgical release of the contracture increased shoulder mobility and decreased compensatory movements. Improvements were maintained for 1 year after surgery with majority of the improvement involving shoulder flexion. Axillary contracture release surgery improves functional shoulder mobility and decreases compensatory motions used during activities of daily living in the first year postrelease. Additional follow-up is needed to evaluate the impact of growth on scar development. (J Burn Care Res 2009;30: ) Pediatric burns account for approximately half of all reported burns, with the majority being due to scald injury. 1 Hypertrophic scars and formation of contractures due to thermal injury are very common in children, and axillary contractures have been among the most difficult to prevent in a burn patient. 2 These contractures, which are caused by normal growth, graft loss or shrinkage, or inadequate therapy, can impact mobility of the shoulder joint. 3 Reconstructive surgical intervention of the axilla is performed to prevent further deformities as well as restore functional joint mobility. 4 Previous research on the effects of axillary contracture on shoulder mobility has focused on the loss of shoulder abduction. 4 9 These studies, which measured active range of motion with a goniometer, documented losses of shoulder abduction before surgical intervention and found increases of shoulder abduction ranging from 15 up to 150 after surgery. Followup for these studies ranged from a few weeks up to 2 years. Although these studies are helpful in illustrating that axillary contractures adversely affect joint mobility, they do not document how the decreased mobility impacts the child s ability to perform activities of daily living (ADL), such as reaching overhead or combing hair. The purposes of this study were to 1) evaluate movement changes that occur after axillary contracture formation and (2) assess the efficacy of surgical contracture release in restoring the functional motion of the affected limb. From the Shriners Hospitals for Children Northern California, Sacramento. Supported by Shriners Hospitals for Children Northern California from grant Address correspondence to Tina Palmieri, MD, Shriners Hospitals for Children Northern California, 2425 Stockton Boulevard Suite 718, Sacramento, California Copyright 2009 by the American Burn Association X/2009 DOI: /BCR.0b013e3181bfb7e5 METHODS Subjects This study was a single-center, prospective study. Children were eligible for the study if they were 2 to 18 years and admitted to Shriners Hospitals for Children Northern California for an axillary burn scar contracture release. Children were excluded if they 1002

2 Volume 30, Number 6 Sison-Williamson et al 1003 were unable to cooperate with the study or had a preexisting neurological impairment. Children were compared to age-matched controls using the same equipment and testing procedures. This study was approved by the University of California Davis Institutional Review Board. All subjects or parents signed informed consent, and children were tested within 1 week before scheduled surgery and at 1, 3, 6, and 12 months postcontracture release. Axillary burn scars were released and a split thickness skin graft was placed over the resultant defect by one of the two burn surgeons. All patients received the same postoperative wound and occupational therapy care. Testing Procedures An eight camera 3-dimensional motion analysis system (Motion Analysis Corporation, Santa Rosa, CA) was used to capture kinematic data. Reflective markers were placed on the seventh cervical spinous process (C7), sternal notch, acromion joints, olecranons, ulnar and radial styloids, hands, and pelvis for use in the upper extremity biomechanical model. 10 The biomechanical model used 10 segments, including the head, neck, shoulder girdle, upper arms, lower arms, hands, and pelvis, to calculate joint motions including neck forward and lateral flexion, shoulder flexion, abduction, and external rotation, elbow flexion, forearm pronation, trunk forward and lateral flexion, and trunk rotation. 10 Subjects were told to stand comfortably with the arms at sides, perform the simulated task one arm at a time, returning arms back to the starting position between tasks. Subjects performed tasks first with the unaffected arm followed by the affected arm. Three simulated ADL were tested. These included high reach, hand to head, and hand to back pocket. High reach simulated reaching for an object overhead; hand to head simulated combing hair; and hand to back pocket simulated toileting. Subjects were tested Figure 2. Hand to head shoulder point of task achievement (PTA) results. *Significance P.05 from presurgical scores. five times; precontracture release and at 1, 3, 6, and 12 months postoperatively. Statistical Analysis Joint positions at the point of task achievement (PTA) were analyzed using one-way repeated-measure analyses of variance. The PTA was established as the point at which the task was considered completed (when the hand was overhead, when the hand was on the top of head, and when the hand was at the back pocket). Post hoc paired t tests were used to compare presurgical values to post 6- and 12-month values for those that showed significant change (P.05). Pre- and postsurgical data at 6 and 12 months were statistically compared with normal data 11 using independent t tests. RESULTS Twenty-three children aged 4 to 17 years (mean age 10 3 years) with axillary burn scar contractures scheduled for surgical release were analyzed. There were 21 boys and 2 girls tested. The TBSA ranged from 14 to 80% (mean 40 6%). Eleven subjects had bilateral contractures and 12 had unilateral contractures making a total of 34 axillary contracture releases analyzed. The control group consisted of children Figure 1. High reach shoulder point of task achievement (PTA) results. *Significance P.05 from presurgical scores. Figure 3. Hand to back pocket shoulder point of task achievement (PTA) results. *Significance P.05 from presurgical scores.

3 1004 Sison-Williamson et al November/December 2009 Table 1. High reach PTA Shoulder flexion 63 (52)* 124 (40)* 125 (15)* 142 (10) Shoulder 39 (17) 29 (12) 32 (14) 34 (9) abduction Elbow flexion 50 (22)* 42 (19)* 35 (20)* 18 (6) Significance from presurgical scores P.05. aged 9 to 12 years tested in the same laboratory using the same equipment and techniques. Surgical Results Figures 1 3 display shoulder pre- and postsurgical results with normal values for the tasks tested. High reach shoulder flexion significantly increased postoperatively. Six and 12 months after surgery, shoulder flexion increased from 60 to 124 and 125, respectively. There were no significant changes in shoulder abduction. Hand to head shoulder flexion significantly increased postoperatively, increasing from 46 to 78 and 73, respectively. Shoulder abduction increased significantly 12 months after surgery from 33 to 43. Hand to back pocket shoulder extension and shoulder abduction increased after surgery, but these did not achieve statistical significance. Comparison to Normal For the high reach task (Table 1), preoperative children demonstrated a significant loss in shoulder flexion (mean loss of 78 ) when compared with normal values. After surgery, shoulder flexion increased; however, values were still significantly smaller than normal values by an average of 17. When data for the full motion of this task are compared with normal control values, shoulder flexion trended toward normalization 1 year after surgery (Figure 4). Preoperatively, the elbow demonstrated a significant increase in elbow flexion (mean increase 32 ) when compared with normal values. Elbow flexion remained significantly higher than normal 6 months and 1 year after surgery by 24 and 17. During the hand to head task (Table 2), preoperative shoulder flexion and shoulder internal rotation had significant losses in motion relative to normal; shoulder flexion had a 37 loss, whereas shoulder internal rotation had a 21 loss. There were no significant differences found in shoulder abduction before release when compared with normal. Neck forward flexion (increase of 7 ) and neck lateral flexion (increase of 12 ) were significantly greater than normal values before release. After surgery, shoulder flexion increased and was within normal range at 6 months postsurgery, but at 12 months postsurgery, values were significantly less than normal by 12. Figure 5 displays full shoulder flexion motion curves for both normal and children with axillary contracture release for the hand to head task. After contracture release, shoulder flexion trended toward normal. However, shoulder internal rotation remained significantly lower for children with contracture release. Shoulder abduction values were within normal ranges preoperatively and 6 months postoperatively but became significantly greater by 7 than normal 12 months postoperatively. Neck flexion and neck lateral flexion decreased and were within normal values postoperatively. Before surgery, there were significant losses in shoulder extension (mean loss of 12 ) and arm pronation (mean loss of 22 ) during the hand to back pocket task (Table 3). Compensatory shoulder abduction values increased significantly (mean increase Figure 4. Mean shoulder joint flexion for all patients. The gray band is the normal range 1 standard deviation.

4 Volume 30, Number 6 Sison-Williamson et al 1005 Table 2. Hand to head PTA of 7 ). After surgery, shoulder extension increased but was still significantly less than normal by 7. Shoulder abduction remained significantly higher than normal postoperatively. Arm supination was significantly less post 6 months surgery but was within normal ranges 1 year after surgery. DISCUSSION Shoulder flexion 46 (27)* 78 (21) 73 (15)* 85 (17) Shoulder 33 (12) 36 (18) 43 (13)* 36 (13) abduction Shoulder internal 11 (21)* 23 (17)* 15 (33)* 32 (15) rotation Neck forward 23 (17)* 15 (9) 13 (9) 15 (8) flexion Neck lateral 15 (12)* 7 (6) 5 (8) 3 (7) flexion Elbow flexion 103 (22) 105 (26) 111 (11) 110 (7) Significance from presurgical scores P.05. The functional outcome of axillary contracture release surgery on ADL has received little attention in the literature. Previous research has relied on passive and active range of motion measurements before and after surgery to conclude whether the patient has improved in terms of function. 4 9 However, these studies do not give insight into how these decreases in range of motion impact functional tasks. This investigation differs in the sense that ADL are evaluated by tasks and captured by 3-dimensional motion analysis technology that allows for objective measures of how patients complete specific tasks. It is important to note that the simulated tasks tested in this investigation did not measure full joint range of motion. Rather, it tested joint motions used during the specific task. The results of this investigation demonstrate that children with axillary contractures use different body mechanics to complete tasks when compared with normal children because their motions of the shoulder were compromised. These compensatory motions usually involved extra movement at the neck or arms. During high reach, patients generally lacked shoulder flexion, so to attain a higher reach, they increased elbow flexion as seen in Table 1. During hand to head, lack of shoulder mobility caused patients to bend their neck forward or to the side to reach their head as seen in Table 2. For hand to back pocket, patients tended to fling their arms outward (shoulder abduction) to move the hand away from the body and around the hip to touch the back pocket as seen in Figure 3. These findings were similar to what was found in previous research. 3 After surgical release of the contracture, there was significant improvement in shoulder flexion (high reach and hand to head) and shoulder extension (back pocket) when compared with their presurgical measurements. However, even though values improved compared with preoperative measurements, values were still significantly smaller than normal. The ultimate or long-term time course of these improvements is unknown. Shoulder abduction did not show many significant differences pre- and postoperatively in this investigation. Shoulder abduction was significantly increased during the hand to head task postsurgery, but during the high reach and hand to back pocket tasks, there Figure 5. Mean shoulder joint flexion for all patients. The gray band is the normal range 1 standard deviation.

5 1006 Sison-Williamson et al November/December 2009 Table 3. Hand to back pocket PTA Shoulder extension 35 (9)* 41 (11)* 40 (6)* 47 (11) Shoulder abduction 9 (9)* 12 (16)* 6 (9)* 2 (5) Shoulder rotation 25 (33) 31 (20) 26 (38) 27 (11) Arm supination 38 (46)* 43 (38)* 54 (42) 61 (16) were no significant differences when compared with presurgical values that is similar to previous findings. 3 During high reach and hand to back pocket, patients used shoulder flexion or extension to complete the task rather than shoulder abduction. When shoulder abduction at PTA during the hand to back task was compared with normal, shoulder abduction continued to be significantly larger at 6 and 12 months postsurgery. But this could be a compensatory action used to complete the task. We would expect to see significant improvements in shoulder abduction, especially because most of the previous research focused on lack of shoulder abduction due to axillary contractures. The tasks tested in this study did not need much shoulder abduction for the task to be completed, which could be a reason why this investigation did not see significant increases as other studies have documented. The compensatory motions used to complete tasks before surgery decreased with increasing shoulder mobility. Elbow flexion at PTA significantly decreased 1 year after surgery during high reach but remained significantly higher than normal. Other than being used as a compensatory motion to increase height of reach, some of the patients could have had elbow contractures that placed their elbows in a more flexed position when compared with normal controls. Neck compensatory motions during the hand to head task decreased after surgery and were within normal ranges 12 months after surgery. The use of increased shoulder abduction during hand to back pocket task continued after surgery because these values continued to be significantly larger than normal. This study documents changes in motion due to axillary contractures and effects of surgical release; however, there were some limitations. All of the patients tested had axillary contractures, but variability in the severity and location of these contractures, which was not controlled. Presence of other contractures could have also affected ability to perform simulated tasks. Child cooperation with task completion could also be variable. Future studies should consider longer follow-up to see whether improvements are sustained, or whether recurrence is common as children grow. Although studies analyzing active and passive range of motion after contracture release exist, they assume that active and passive range of motion are appropriate surrogates for functional range of motion. Motion analysis, which analyzes movement during ADL, measures how a contracture changes actual functional motion. Increased use of motion analysis in the assessment of surgical outcomes would be beneficial to document objective movement during specific tasks. In conclusion, this investigation suggests that surgical correction of axillary contractures results in continued improvement of functional movement patterns at the shoulder and decreases compensatory motions used to complete tasks up to 1 year postsurgery. Motion analysis objectively quantifies patient movement before and after surgical treatment and may be valuable in the comparison of functional outcomes using different therapies for children with axillary contracture release. REFERENCES 1. Passaretti D, Billmire DA. Management of pediatric burns. J Craniofac Surg 2003;14: Larson DL, Abston S, Willis B, et al. Contracture and scar formation in the burn patient. Clin Plast Surg 1974;1: Palmieri TL, Petuskey K, Bagley A, Takashiba S, Greenhalgh DG, Rab GT. 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