POST BURN CONTRACTURE

Dr. S. M. TAHIR.
Professor
Plastic & Burn Surgery.
Muhammad Medical College
Intro:

 We are familiar with scar,

hypertrophic scar.
 Now we will try to understand
why scar contract and how
contracture develops.
 The healing of a burn wound
 Restitution (Regeneration)

 Substitution (substitutive unspecialized

connective)
 Fibroblasts,
 Myofibroblastsand
 Collagen deposition.
 The haphazard deposition of Fibroblast,
Myofibroblast and Collage (ECM), in an
open wound causes concentric reduction in
the size of the wound.
 This process is knows as Wound

Contraction
 The end result of the process of
contraction is Scar contracture.
Contracture?

 A Scar is result of pathologic wound

healing after trauma due to Burn,
Traumatic injuries and Surgeries.
 As such Scar do not pose any health

hazard, however when contact,

leading to contracture formation.
Pathophysiology of Scars & Contracture

 Wound healing proceeds through

overlapping stages.
Coagulation.
Inflammatory.
Proliferative.
Remodeling.
 When something went wrong during
Proliferative stage (3rd stage), leading to
Persistent activation of myofibroblasts,
Imbalance of deposition and
degradation of ECM, and
Poor arrangement of newly formed
fibers lead to scar/contracture
formation.
 Delayed healing lead to
overproduction of Myofibroblast.
 80% of the wound become

hypertrophied if healing is delayed

beyond 21 days.
 Hypertrophic scar when cross joint
lead to contracture formation.
Myofibroblast?

Smooth
Muscle Cell
of Vessels
Fibroblast Epidermal
(Major Source) Stem Cells

Myo
 Myofibroblasts, play an essential role in
the induction and maintenance of scar
contracture.
 In normal acute wound healing, the
myofibroblasts are temporally limited
and cleared by apoptosis in the
Remodeling phase when the tissues are
repaired.
Activation of Myo
 Transforming Growth Factor (TGF) is found in all
tissues and has three isomers, β1, β2, and β3.
 TGF-β1 is an inducer of myofibroblast
differentiation.
 In addition, many other growth factors show positive
role in myofibroblast differentiation, such as
connective tissue growth factor (CTGF), platelet-
derived growth factor (PDGF), insulin growth factor
(IGF), and vascular endothelial growth factor
(VEGF)
Deactivation of Myofibroblast
 Myofibroblast activity is also being cheeked
by suppressing activity of TGF β1
 These includes:

 Basic fibroblast growth factor (bFGF, FGF2),

 Epidermal growth factor (EGF),

 Interferon-γ (IFN-γ), interleukin-10 (IL-10),

prostaglandin E2 (PGE2), and
 TGF-β3
 In the wound repair phase, wound
contraction is helpful to close the original
wound by reducing its surface area.
 However it is the continuation of
contraction after wound healing that
leads to the contracture formation.
 Contracture usually develops in flexion.
Why ?
 Scar contracture cause
Dysfunction.
Disfigurement.
Poor quality of life.
Pain.
Psychological consequences
How to know the Dysfunction?
 Dysfunction is determined by reduction in the range
of movement (ROM) at a joint.
 Therefore the most important contracture sites are
the joints of the upper limb, neck, mouth, trunk and
knees.
 These contractures can impair the patient’s ability to
move, to dress, to eat or drink and perform fine
skills.
A thick linear contracture band of the neck and peri-orbital contracture
Axillary contractures: greatly reduce the range of abduction, flexion and
extension of the shoulder.
Linear contracture band on the palmar aspect of the middle finger. The little
finger is unable to extend at the Proximal Interphalangeal Joint and at the
Distal Interphalangeal Joint.
Diffuse Contracture of Axilla and Elbow Joint: ROM Markedly Reduced.
 Contracture of Neck: Limitation of Movement.
What are other features?.

?
Molecular Basis of Contracture

 Contracture are usually seen at areas

where which are frequently subjected
to the high stretch tension from the
natural daily movements of the body.
 What factors transcript this daily

movement into force that ultimately

lead to contracture?
 α-smooth Greater is Exogenous
muscle actin
(α-SMA) is a the stress, mechanical force,
when applied
More is the through
mechano- integrins,
sensitive expression enhances the
protein that of α-SMA activation of
induces a serum response
rapid factor (SRF) and
mechanism to increases α-SMA
control the transcription and
myofibroblast incorporation into
contractile actin filaments.
function.
Principles of surgical contracture
release and reconstruction
 Contracture must be released when it is
fully “matured”.
 When spilt thickness graft is applied after
release of immature contracture,
potentiality of wound contraction
continues and there is chances of
recurrent contracture.
Contracture Release & Surgical Procedure

• PTSG • FTSG

Maximum
contraction. Showed
Covered area contraction. 87%
reduced to 85% in at 3 months while
3 months and at at 12 months
12 months further reduced to 92%
reduced to 75%

Negligible if any Grow with growth

contraction. of the pt. Covered
Surface area at 3- area is 123% after
12 months is in 3 months and
range of 97-98% 142% percent
after 12 months.
• LOCAL • Perforator
Flap Based
Flap
Multiple post-burn scar and scar contractures in
an adult female
Post-burn hypertrophic scar on anterior chest
wall.
Post operative result after release and skin
grafting of the patient
Same patient as in previous Figure.
Non Healing Post Burn Wound in young Female
Same patient as in Previous figure, managed by
PTSG
Axillary contracture: Anterior axillary Fold only
Axillary contracture managed by Z plasty
Elbow Contracture
Elbow Contracture: Managed by Z plasty.
Late Post Operative results:
Contracture of index finger volar surface with Z-plasty.
Release of little finger volar contracture with full-thickness skin graft from
planter region of the foot.
Prevention
 Top Five Ways to Prevent Burn Contractures:
Appropriate positioning of affected
limb.
Cover the burn early (the first 2-3
weeks)
Splint day and partly during night.
Prevent infection.
Stretch.
Prevention

 During early period, the collagen

and elastin are relatively un-cross
linked and malleable. Therefore
 Gentle, passive and sustained

stretching is an effective technique

for the lengthening of bands of scar
tissue and increasing range of motion.
Prevention

 Compression garments .
 Timing?

Before development of hypertrophic

scar.
Newly healed skin is delicate and
therefore must be preconditioned
appropriately to accept the stress and
pressure exerted by CG.
Pressure Garments
 The ideal pressure required not known.
 Mostly used at 24 mm Hg, this counteract
capillary pressure.
 Pressure therapy diminishes the number of

 Myofibroblasts.

 Erythema.

 Thicknessand firmness of hypertrophic scar and

 Accelerates scar maturation.
Pressure Garments
 Mechanism of action not known.
 Pressure causes hypoxia of the scar tissue by
occlusion of the microvasculature.
 Increased collagenase is released that causes
collagen breakdown.
 Reduction in tissue edema.

 Encourage reorientation of collagen fibers into

uniform, parallel patterns as opposed to the
whorled pattern seen in untreated scars.
 Diffuse contracture.
 Re-contracture, after
grafting.
 Positioning in Bed
Ventral part of the neck Slight extension

Shoulder 90° abduction, 15-20° adduction, neutral rotation

Arm Elbow extended, arm in supination
Hand, dorsal part Wrist in15-20° extension, at MCP joints in 60-90°
flexion, IP joints in total extension
Hand extensor Like above, but MCP joints in 30-40° extension
Palm Wrist in15-20° extension, fingers and MCP joints in
total extension, thumb in board palmar abduction
Hip Abduction (10-15°), in total extension & neutrally
rotated
Foot Hips in abduction(10-15°), in total extension and
neutrally rotated Knee extension, ankle in 90°
Dorsiflexion.
Prevention
Prevention
Prevention
Physiotherapy

 Physiotherapy is a key component.

 Should be started as early as

possible, after the operation is

performed.
 The main goal of the physiotherapist

should be to maintain the length

gained by surgery.
 PT helps by
 Scar massage: Decrease hypertrophic
scarring.
 Stretching muscles that have been
contracted.
 Providing appropriate pressure garments
and splints to prevent re-contracture.
 Providing serial casting to help heal the
wound and stretch tissues.
Scar Massage
 Particularly important to do in areas where
scar formation has made the skin tight, hard, or
difficult to move, a condition known as
adhesion.
 Using thumbs can be done

 In circular motions.
 Thumbs down on the scar and then pull them apart,
stretching the skin in between them
Scar Massage
Mobilization

 To prevent re-contracture
stretch/mobilization is necessary.
 There are three types of mobilization:
 ACTIVE.
 ACTIVE ASSISTED and
 PASSIVE.
 ACTIVE MOBILIZATION is movement that
the patient performs himself with only the
antagonistic muscles of their affected limb
or digit.
 Movement is not forced.

 This can be done as soon as a week after

surgery if the graft is healthy and has a

good take.
 Active
Mobilization.
 Antagonist
muscles
 ACTIVE ASSISTED MOBILIZATION is when the
patient attempts to move their limb by
themselves but uses their other hand to increase
the stretch or range of motion.
 If mobilizing a lower limb, it is often helpful for
a physiotherapist to assist the patient.
 Active assisted mobilization is usually done 2
weeks after surgery, when the sutures are
removed.
 PASSIVE MOBILIZATION : when the
patient does not attempt to move their
affected limb or digit themselves.
 Instead, they are supposed to relax and
allow a physiotherapist to move their limb
or digit into the appropriate stretch.
 Passive mobilization should be started
three weeks after surgery.
 Passive mobilization can also be done
pre-operatively on patients with partial
contractures waiting for surgery.

 These stretches must be done for 5-10

minutes three times a day for a month
before their surgery.
 Passive
Mobilization.
 Always
stabilize the
proximal joint:
if stretching the
wrist, stabilize
at the forearm,
if stretching the
thumb, stabilize
at the
metacarpal
and wrist.
 30-60 mins at
least.
Muscle Strengthening
 Most patients do not have decreased muscle
power, only a decreased range of motion due
to a contracture of skin and tendons.
 Physiotherapy works on strengthening the
muscles that would counteract re-contracture.
 For example, if a patient has a flexion elbow
contracture, the physiotherapist should stretch
the biceps and strengthen the triceps.
Physiotherapy AXILLA
Fingers
 Game Therapy.
 As sensation might be
limited, start with
picking up small, firm,
light weight objects and
progress to handling
large, flexible, soft, and
heavy objects.
 As a simple task patient
is asked to touch their
thumb to each finger.
Thumbs
Knee Physiotherapy
 Active Mobilization.
 Soon after suture removal patient is asked to
attempt flex & extend knee within their pain
tolerance.
 Simplest way is to have them sit on their bed so that
their feet dangle off the side and ask them to raise
their foot to your hand.
Knee Physiotherapy

 Passive Mobilization.
 For a flexion contracture,
 positioning the patient face
down on a table so that their
foot is raised in the air.
Stabilize the proximal side of
the joint by gripping the back
of the thigh, just above the
knee, with one hand.
 With the other hand, grip just
below the calf and start to
gently press the ankle
towards the table.
Game Therapy

 Once wound is healed, physiotherapists

should introduce game therapy to their
patients.
 Game therapy uses games or fun
activities as a way to encourage their
patients to stretch, increase muscle
strength, and range of motion.
Game Therapy
SPLINT & SERIAL CASTING
Splinting/Cast is essential component in the
management of contracture.
Why Splint ?

 To immobilize a skin graft after surgery.

 To protect vulnerable structures e.g.
exposed tendon.
 To prevent skin and tendon contracture.

 To maintain the joint range when the

patient is unable to do so e.g. post-
operatively and young children.
 To prevent long term deformity.
Splinting
 Splints decrease the likelihood of developing
hypertrophic scars and decrease the chance of re-
contracture.
 Usually used to immobilize the joint as early as
after surgery to prevent the graft from sloughing
off due to motion or hematoma.
 There are two types of splints:
 Dynamic splints and

 Static splints.
Dynamic Splint

Dynamic splints allow

movement against
resistance.
These splints are usually

worn during the day only.

Static Splint

 Static splints immobilize the joint

completely and are usually worn
at night.
 Splints worn during the day should

only be removed when the patient

is doing rehabilitation exercises.
HAND

 Static Splint

 Dynamic Splint
Serial Casting

 When after Release of contractures if

splint are difficult to apply due to
deformed anatomy than serial casting is
useful.
 In such cases, casts might be put on as

early as 2nd -3rd postoperative day.

 The cast is changed less frequently.
 The idea is to prevent contracture and to improve
range of motion therefore Splinting and Exercise
are used in combination.
 Splint are removed during exercise.
 For exercise follow the recommendation of
Physiotherapists.
Serial Casting

 Increase ROM achieved after

reconstructive surgery, but it is feared that
it may decreased for some reason.
 Initial casting is applied where ROM
allows.
 Position is gradually change over

repeated casting to get

normal/acceptable ROM.
Position ?

Splint/Serial cast is applied in FUNCTIONAL POSITION

 Palmar extension splint (for
Thumb web space ‘C’ splint
palmar burn)
 Custom made soft collar with chin
Neck extension support
straps
“Toe down” splint Knee extension splint
Paediatric axilla splint supine Pediatric axilla splint side lying
Splint: General Principles
 Splints will be worn at night until the scar is mature
and during the day when the scar is active.
 Gradually the day regime includes more periods
with splints off e.g. two hours on, two hours off.
 Frequent checking of splint fitting for e.g. due to
child’s growth, wear &tear
 Environmental issues e.g. excessive sweating in hot
weather may require more frequent cleaning or
additional linings.
Precaution
 Continual checking and remolding needs to be done
to ensure that the goals of the splinting regime are
being achieved.
 Check for issues that will require possible
adjustment of the splint such as changes in edema,
breakdown, fragile skin, changes in ROM,
maceration.
 Ensure appropriate hygiene and cleaning of splints
and skin.
Material for Serial Cast/Splint

 Plaster of Paris.
 Cardboard

 Foam and blown polystyrene

 PVC piping

 Thermoplast
POP
 Most frequently
used
postoperatively.
However problems
associated are
 Absorbs secretion.
 Tends to break.
 Heavy.
Cardboard

 Excellent early
splint material.
 Particularly good
for children.
 Lightweight, can
be get from
medicines boxes.
 Foam and blown polystyrene

 Excellent for maintaining position of large joints

 Can be used in conjunction with PVC to create hand splints.
Polystyrene
PVC (Polymerizing Vinyl Chloride)

 Lightweight
 It can be cut with

a saw & shaped

with heavy duty
scissors.
 Useful for knee,
arm and finger
extension splints.
PVC piping

PVC PIPES. PADDED FABRICATED

INTO
AXILLARY
SPLINTS
PVC for Elbow
PVC

 Electric heat gun can be use to fabricate PVC.

Thermoplast
 Thermoplast (Hexelite@)is a thermoplastic
polyester material supplied in rolls and also as
splints of various sizes from 5 to 15 cm in width.
 After heating in a water bath to 80°C for 5 minutes
the material softens and can be applied.
 The elastic strength of the material is regained by
cooling to room temperature, but the material can
be softened again by reheating if it stiffens before
use.
 The application of the warmed material after
squeezing off any excess water using towels is
almost the same as for plaster.
 After half an hour of cooling at room temperature
the bandage has gained its full strength for use.
Thermoplast
Scarf/Duppata
 Make an
excellent
postural
support
to stretch
scarring
to the
chest and
axillae.
Education
 To ensure positive attitude of the patient, it is
essential to inform patient about every stage of the
rehabilitation.
 Education is of paramount importance along with a
consistent approach from all members of the
multidisciplinary team.
 Initial reluctance due to frustration, pain and
fatigue is to be countered by encouragement and
education.
Psychological impact
 Except for very superficial/minor burn, all burn
victim needs psychological support.
 The problem of anxiety/depression usually start
soon after the incidence.
 When overlooked early, may be difficult to dealt
with later.
 Therefore phycological support should be offered
to every burn victim.
THANK
YOU