RESUMEN

A female patient in her early 60s was diagnosed with squamous cell carcinoma of right buccal mucosa. Interestingly, the patient also presented with post-burn contractures of face, neck and chest which posed significant anaesthetic and surgical challenges, thus making this case report unique. Through this case report, we highlight the reflections in management of such a case.

RESUMEN

Introduction: Burns are most prevalent in low- and middle-income countries but the risk factors for burn contractures in these settings are poorly understood. There is some evidence from low- and middle-income country studies to suggest that non-medical factors such as socio-economic and health system issues may be as, or possibly more, important than biomedical factors in the development of post-burn contractures. Methods: Four cases are presented to illustrate the impact of non-biomedical factors on contracture outcomes in a low-income setting. The cases were drawn from participants in a cross-sectional study which examined risk factors for contracture in Bangladesh. Discussion: The two cases had similar burns but different standards of care for socio-economic reasons, leading to very different contracture outcomes The two cases both had access to specialist care but had very different contracture outcomes for non-medical reasons. The risk factors and contracture outcomes in each case are documented and compared. Conclusion: The impact of non-biomedical factors in contracture development after burns in low- and middle-income countries is highlighted and discussed. Lay Summary: Burns are common in low- and middle-income countries (LMICs) but the risk factors for burn contractures in these settings are poorly understood. Burn contractures are formed when scarring from a burn injury is near or over a joint and results in limited movement. There is some evidence from LMIC studies which suggests that non-medical factors such as socio-economic (e.g., household income, level of education) and health system issues (e.g., whether specialist burn care could be accessed) may be as, or possibly more, important than non-medical factors (such as the type and depth of burn and the treatments received) in the development of contractures following burn injuries.Four cases are presented to illustrate the impact of non-biomedical factors on contracture outcomes in a low-income setting. The cases were drawn from participants in a larger study which examined risk factors for contracture in Bangladesh. Two cases had similar burns but different standards of care and different outcomes. Two cases had similar access to specialist care but very different outcomes for non-medical reasons. The risk factors present and contractures outcomes in each case are documented and compared.The importance of non-biomedical factors in contracture development after burns in LMICs is highlighted and discussed.

RESUMEN

Contractures are a frequent consequence of burn injuries, yet our knowledge of associated risk factors is limited. This paper provides an extensive review of relevant literature from both High-Income Countries (HICs) and Low-Middle Income Countries (LMICs). Ninety-four papers (up to June 2019) and eight subsequent publications (up to March 2022) were included, 76% of which were from HICs. The majority of publications were either descriptive studies (4 from HICs, 9 from LMICs) or papers citing putative risk factors (37 from HICs, 10 from LMICs). Seventeen publications (all from HICs) reported on the effects of individual non-surgical therapeutic interventions, often with conflicting results. Two published systematic reviews emphasised the poor quality of evidence available. Only fifteen studies (3 from LMICs) examined potential contracture risk factors with statistical comparisons of outcomes; significant findings from these included demographic, burn, comorbidities, and treatment risk factors. LMIC papers included socioeconomic and healthcare system factors as potential risks for contracture; these were rarely considered in HIC publications. Methodological issues identified from this review of literature included differences in contracture definitions, populations studied, standards of care, joints included and the timing and nature of contracture assessments.This review is the first to collate existing knowledge on risk factors for burn contractures from both HIC and LMIC settings, revealing a surprising lack of robust evidence for many accepted risk factors. In LMICs, where burns are particularly common, universal health provision is lacking and specialist burn care is both scarce and difficult to access; consequently, socioeconomic factors may have more immediate impact on contracture outcomes than specific burn treatments or therapies. Much more work is indicated to fully understand the relative impacts of risk factors in different settings so that context-appropriate contracture prevention strategies can be developed.

Asunto(s)

RESUMEN

We find a lack of high-quality published evidence on risk factors for burn contracture formation. The vast majority of research is from High Income Countries (HICs), where many potential risk factors are controlled for by standardised and high-quality healthcare systems. To augment the published literature, burn care professionals with Low Middle Income Countries (LMICs) experience were interviewed for their opinion on risk factors for burn contracture formation. Participants were also asked for their views on identification and measurement of contracture. Seventeen semi-structured interviews were conducted (13 burn surgeons and 4 therapists). The average length of experience in burn-care was 13 years. Participants represented Ghana, Ethiopia, Malawi, Nigeria, South Africa, Nepal, and India. Participants reported ninety risk factors. Risk factors were later collated according to topic: Non burn individual factors (n = 13), Burn injury factors (n = 14), Family and community factors (n = 9), Treatment factors (n = 18), Complications (n = 2), Healthcare capacity factors (n = 19) and Societal and environmental factors (n = 12). The top five most frequently cited risk factors were lack of splinting, lack of physiotherapy, lack of early excision and skin grafting, low socioeconomic status and presence of infection. Although participants had no doubts that they could recognise a contracture, none provided a standardised system of measurement or an operational definition of contracture. Burn care professionals have a wealth of experience and untapped knowledge of risk factors for burn contracture formation in their own population base, but many of the risk factors highlighted by participants have not yet been explored in the literature. Variations in clinicians' diagnosis and measurement of a burn contracture underscores the need for an agreed, standardised, simple and easily reproducible method of diagnosing and classifying burn contractures.

Asunto(s)

RESUMEN

Risk factors for burn contractures require further study, especially in low and middle-income countries (LMICs); existing research has been predominantly conducted in high income countries (HICs). This study aimed to identify risk factors for burn contractures of major joints in a low-income setting. Potential risk factors (n = 104) for burn contracture were identified from the literature and a survey of clinicians with extensive experience in low and middle-income countries (LMIC). An observational cross-sectional study of adult burn survivors was undertaken in Bangladesh to evaluate as many of these risk factors as were feasible against contracture presence and severity. Forty-eight potential risk factors were examined in 48 adult patients with 126 major joints at risk (median 3 per participant) at a median of 2.5 years after burn injury. Contractures were present in 77% of participants and 52% of joints overall. Contracture severity was determined by measurement of loss of movement at all joints at risk. Person level risk factors were defined as those that were common to all joints at risk for the participant and only documented once, whilst joint level risk factors were documented for each of the participant's included joints at risk. Person level risk factors which were significantly correlated with loss of range of movement (ROM) included employment status, full thickness burns, refusal of skin graft, discharged against medical advice, low frequency of follow up and lack of awareness of contracture development. Significant joint level risk factors for loss of ROM included anatomical location, non-grafted burns, and lack of pressure therapy. This study has examined the largest number of potential contracture risk factors in an LMIC setting to date. A key finding was that risk factors for contracture in low-income settings may differ substantially from those seen in high income countries, which has implications for effective prevention strategies in these countries. Better whole person and joint outcome measures are required for accurate determination of risk factors for burn contracture. Recommendations for planning and reporting on future contracture risk factor studies are made.

Asunto(s)

RESUMEN

Post-burn contractures are common entities seen in developing countries. There are multiple reasons for the development of contractures, most are preventable. In extensive contractures, a strategic plan is necessary to release all contractures and yet not antagonize post-operative positions. It is also necessary to be cost-effective and minimize the number of surgeries needed. Conventionally the release sequence in extensive burn contractures is proximal to distal. In this case report, we discuss an unusual sequence where we released distal contractures before the proximal to achieve optimum results. A 3-year-old child with post-burn contracture of hand, wrist, elbow, and axilla was treated in 2 stages, with the release of wrist contracture and cover with pedicled abdominal flap in the first stage and division of pedicled flap with the release of axilla and elbow contracture in the second stage. Thus, the release of all contractures was achieved without antagonizing post-operative positions and minimized the number of surgeries. A case-based approach may be crucial in making a strategic surgical plan to minimize the rehabilitation phase, rather than following known dictums.

Asunto(s)

RESUMEN

Post-burn contractures are common entities seen in developing countries. There are multiple reasons for the development of contractures, most are preventable. In extensive contractures, a strategic plan is necessary to release all contractures and yet not antagonize post-operative positions. It is also necessary to be cost-effective and minimize the number of surgeries needed. Conventionally the release sequence in extensive burn contractures is proximal to distal. In this case report, we discuss an unusual sequence where we released distal contractures before the proximal to achieve optimum results. A 3-year-old child with post-burn contracture of hand, wrist, elbow, and axilla was treated in 2 stages, with the release of wrist contracture and cover with pedicled abdominal flap in the first stage and division of pedicled flap with the release of axilla and elbow contracture in the second stage. Thus, the release of all contractures was achieved without antagonizing post-operative positions and minimized the number of surgeries. A case-based approach may be crucial in making a strategic surgical plan to minimize the rehabilitation phase, rather than following known dictums.

Asunto(s)

RESUMEN

Burn injury may result in psychological and physical disability. Post-burn contractures, a poor outcome of the wound healing process, may limit the movement at the joints and impair the quality of life of the survivors. To compare outcomes of paraffin wax bath therapy and therapeutic ultrasound in post-burn contractures of small joints of the hand; eighty patients with post-burn contractures were enrolled in this study. Patients were divided into two groups; group I (n=40) was treated with ultrasound therapy and group II (n=40) with paraffin wax bath therapy, while stretching exercises & protocols for massage of the burn scar contracture were the same for both groups. The study participants were assessed for passive range of motion (P-ROM) for the extension at inter-phalangeal (IP) joints of the involved finger at the first contact session and the end of the 8th week of the treatment. The mean age of the patients was 25.62 years in Group-I and 24.67 years in group II. Group-I had 29 (72.5%) males and 11 (27.5%) females and group-II had 37 (92.5%) males and 37.5%) females. After 8 weeks of treatment, Group-I displayed improvement in range of motion with a mean increase of 4.97 ± SD 0.94 degrees while Group-II showed a mean increase of 9.37 ± SD 4.41 degrees with P value of <0.005. Paraffin wax therapy with stretching exercises and massage were more effective as compared to ultrasound therapy with stretching exercises and massage for the management of post-burn contractures of small joints of the hand.

RESUMEN

This study aims to present the outcomes from current alternative treatment modalities combined with the conventional techniques used in the treatment of burn contractures. Twenty-nine patients were included in the study. Patients were divided into three groups according to the severity of contractures: 1- mild, 2- moderate, and 3- severe. Skin defects that occurred following the incision and scar contracture release were closed with a collagen-elastin acellular dermal matrix (ADM). The split-thickness skin graft was evenly placed on the ADM and fixed with absorbable sutures. The grafts were closed with NPWT (negative pressure wound therapy system) dressings. In platelet-rich plasma (PRP) mild cases as well as moderate and severe PRP cases, stem cell and fat injection were applied. PRP injection was applied to the scar base before the contracture; fat injection and stem cells were applied at the 3rd and 6th months. Preoperative and postoperative range of motion (ROM), Patient and Observer Scars Evaluation Scale (POSAS), and histopathological scores were evaluated. There was a statistically significant decrease in postoperative POSAS scores (p < .05) and a significant increase in the ROM score (p < .05). Histopathological examination revealed an increased postoperative collagen accumulation and organization, increased vascularization, decreased scar tissue thickness and increased subcutaneous tissue thickness. There was no difference in treatment outcomes between the groups.Based on the current findings, we conclude that ADM, stem cell-rich fat grafting, and PRP therapies combined with conventional methods could satisfactorily improve functional outcomes in the repair of burn contractures.

Asunto(s)

RESUMEN

Measuring the extent and impact of a health problem is key to being able to address it appropriately. This review uses available information within the framework of the Global Burden of Disease studies to estimate the disease burden due to burn injuries of the hands. The GBD indicates that since 1990 there has been an approximately 30% decrease in the disease burden related to burn injuries. The GBD methods have not been applied specifically to hand burns, but from available data, it is estimated that about 18 million people in the world suffer from sequelae of burns to the hands.

Asunto(s)

RESUMEN

A study was carried out regarding 213 patients of either gender and all ages who presented with post-burn contractures. The commonest site of contracture was the neck. 92 patients (43.19%) had received their initial burn injury management in general surgery units in tertiary care hospitals compared to 43 patients (20.18%) in district headquarter hospitals. Only 26 patients (12.20%) were managed in plastic surgery/burn wards, and 52 patients (24.41%) received no regular treatment from any hospital. The majority of patients (n=197) had a history of conservative management, with only 16 patients (7.51%) having a split thickness skin graft for part of their initial burns. None of the patients had the appropriate anti-deformity splintage in the affected parts or any physiotherapy during the acute phase of their burns.

Cette étude décrit 213 patients des deux sexes et de tous les âges qui se sont présentés à cause des contractures dues aux brûlures. Le cou était la partie du corps la plus atteinte comme site de contracture. 92 patients (43,19%) ont reçu leur prise en charge initiale dans une unité de chirurgie générale de l'hôpital pour les soins tertiaires et 43 patients (20,18%) dans les hôpitaux de district. Seulement 26 patients (12,20%) ont été traités en chirurgie plastique tandis que 52 patients (24,41%) n'ont reçu aucun traitement particulier dans aucun hôpital. La majorité des patients (n = 197) ont reçu un traitement conservatif pour les brûlures et seulement 16 patients (7,51%) ont bénéficié d'une greffe cutanée d'épaisseur variable pour une part de leurs lésions. Aucun des patients n'a eu le splintage anti-déformation appropriée ni la physiothérapie nécessaire au cours du traitement dans la phase aiguë des brûlures.

RESUMEN

AIM: An overview of a series of severe burn contractures in 44 hands reconstructed over a 20 month period with an easy to follow algorithm. SETTINGS AND DESIGN: The series was carried out by a single surgeon at Green Pastures Rehabilitation Centre in Pokhara, Nepal. All patients attending with severe burn contractures to the hand were included in the series. MATERIALS AND METHODS: This is a retrospective review of burn contractures in a total of 44 hands. All the contractures involved limitation of movement by 60 degrees in two or more joints or by 80 degrees in one joint. The decision making process is presented as a flow chart indicating when and which flaps were used. RESULTS: Illustrations demonstrate what was achieved, with all hands obtaining an improvement in function. CONCLUSIONS: Although many of these contractures can be dealt with by skin grafting the series clearly illustrates the indications for flap coverage.

RESUMEN

A new method for release of severe mentosternal contractures has been described in this paper under central neuraxial blockade. The contracture release was performed under thoracic epidural analgesia. This technique can benefit patients with mentosternal contractures to avoid the problems of entubation and it can also assist in postoperative recovery and analgesia. The epidural catheter can be used to extend the height or duration of intraoperative block and is also useful to provide postoperative epidural analgesia.