Contracture Release and Full-Thickness Skin Graft to Volar Index Finger with K-Wire Insertion

Abstract

Trauma-related deaths cause many deaths per year, with burns contributing to many of these deaths. The morbidity and mortality of burns have shown a decline since the development of more scrupulous management. The complications stemming from a poorly-healed burn wound can lead to functional deficits and overall aesthetically unfavorable results leading to psychological distress. Due to the inquisitive nature of infants and toddlers, and their nature to learn the world with their hands, their sensitive regions like the hands become likely targets for burns. The rapid growth of infants places extra stress on the surgeon to recreate the normal anatomy of the flawed hand. Management differs depending on the size and depth of the burn wound. Superficial burns can be managed on an outpatient basis with spontaneous healing expected in 2 or 3 days with minimal scarring. Deep burns, particularly in pediatric populations, need considerable attention to avoid secondary contracture that leads to deformity. Many treatment options exist, but in sensitive areas like the hands and face, full-thickness skin grafts are favored due to their superior healing and decreased likelihood of secondary contracture. Advancements in modern medicine have expanded treatment options with nonoperative and operative procedures, along with the utilization of growth factors, such as TGF-B1 that accelerate healing. This article aims to guide the surgeon in managing a pediatric burn wound with an arsenal of treatment options with the goal of achieving full mobility and functionality of the hand.

Keywords

Post-burn; hand deformity; pediatric; contracture; skin transplantation.

Background

Burn injuries are a major global health issue due to their high morbidity and mortality. The cutaneous scarring caused by superficial and full-thickness burns leads to functional impairment and aesthetically unpleasing results leading to psychological distress. In the first four decades of life, trauma is the leading cause of death and disability, with burn trauma comprising the second most common cause of trauma-related death.¹

In cases of superficial hand burns, the return of normal function occurs in 97% of cases, compared to 81% in deep burns.²  Pediatric hand burns pose more risk for functional and aesthetic deterioration due to the rapid growth during childhood and should be treated promptly.³

Contracture of the wound occurs secondary to the interruption of the normal physiologic phases of wound healing: inflammation, proliferation, and remodeling of local tissue.⁴ For deep burns, in particular, the activation of dermal fibroblasts leads to large quantities of collagen and inflammatory cytokines with less collagenase to break down collagen.⁴ When fibrocytes migrate from the bone marrow to the injured tissue, they differentiate into fibroblasts and then eventually myofibroblasts, leading to wound contracture.⁴ When there is a dysregulation between increased type III collagen and decreased type collagen I, this can lead to the formation of hypertrophic contracted scar.⁴

For our patient, the release of the skin contracture was accomplished via an incision, followed by K-insertion to prevent skin graft loss by inhibiting flexion postoperatively. Our full-thickness skin graft was harvested from the groin region of the patient. An appropriate dressing was added to the skin graft.

Focused History of the Patient

A 1-year-old male patient presented to Shriners Hospital for Children following a burn accident 1 year ago. The patient has noticeable scarring near the proximal portion of the index finger with obvious contracture in the flexed position. Prior imaging is unknown at this time. All other patient history is unknown at this time.

Physical Exam

The physical exam findings seen in this patient were consistent with a moderate decrease in the range of motion and minimal distortion of the index finger. Noticeable scarring was found along the volar aspect on the index finger with evidence of contracture leading to a persistently flexed finger. No other significant findings were noted. 

Natural History

The natural history of hand burns depends on the extent of the injury and the location. Injury develops due to direct thermal damage or secondary to the intrinsic minus position from edema and vascular insufficiency.² As discussed earlier, normal hand function is returned in 97% of patients with superficial burns compared to 81% of deep burns. Contraction is the method that deep burns are healed by, and the extent of contracture depends on the amount of skin lost due to the deep burn.² Palmar burns result in lax dorsal skin, which allows edema to accumulate causing distortion of the anatomical structures in the hand.² Edema accumulation can lead to compartment syndrome, which needs urgent attention before intrinsic muscle ischemia and distal vascular compromise take place.² If a superficial burn is noted on a physical exam, it is appropriate to follow the patient on an outpatient basis, however, major burns are an indication for hospital admission.

Regaining full range of motion is the goal when it comes to hand wounds and is optimized with intensive rehabilitation programs starting from day one. Early mobilization once the edema has subsided is an important step as it allows faster recovery.² Passive stretching of the healing skin is allowed if the burn is left alone for spontaneous healing. On the contrary, active finger movement is encouraged when skin grafting has occurred, preventing the graft from shearing.²

Options for Treatment 

Burn wounds have a multitude of options for treatment ranging from conservative to surgical to biological. With advancements in science and regenerative medicine, treatment options have flourished. The best outcome of a hand burn is when deformities are prevented from developing in the first place. This can be achieved from urgent hand resuscitation during the acute phase, excisional surgery, reconstructive surgery, and physiotherapy. An individual runs the risk of hand deformities when these procedures are not done.²

There are multiple treatment methods available for burn wounds. These include surgical interventions such as skin grafting with K-wire insertion, and non-operative treatments. Non-operative treatments can consist of an antiseptic dressing and aggressive physical therapy to avoid deformities from developing. It’s important to note that these are just some of the methods, and the choice of treatment can depend on various factors such as the nature and extent of the burn wound, a particular wound quality or state, and the patient’s allergy history.³

When deciding what skin graft technique to use, one should consider the pros and cons of full-thickness skin grafts vs. split-thickness skin grafts. Full-thickness skin grafts have superiority over split-thickness skin grafts in terms of their functionality and cosmetic result. Additionally, secondary contraction is minimal in full-thickness skin grafting, and skin color matching is more accurate.³ 

Occasionally, when a boutonniere or swan neck deformity is evident to happen, early release of the tissue is indicated to prevent attenuation of the extensor apparatus. This comprehensive approach to postoperative care can significantly improve the healing process and the patient’s quality of life.⁵

In addition to skin grafts, there are other surgical options that can be considered. One such option is skin rearrangement, also known as Z-plasty. Z-plasty is a surgical procedure that involves making a Z-shaped incision along the line of the greatest tension of a scar. The upper and lower triangular flaps are then ‘switched’ to the opposite positions. This technique is used to elongate the scar, thus reducing tension and improving both the functional and cosmetic appearance of the scars.¹¹

Another option is the use of more complex skin donor flaps. These flaps, which bring their own blood supply from the flap donor site, can be used depending on the location of the scar and a patient’s personal goals. These procedures can be particularly beneficial for large grafts and flaps, and may require an inpatient stay.¹²

Postoperative emollients such as antibiotic ointments or creams are often used to keep the wound moist, prevent or treat infections, and aid in the healing process. These emollients can also help to reduce inflammation and accelerate the healing process.¹³

Massage is another important postoperative measure. It can help to stimulate the lymphatic system, aiding in the drainage of excess fluid, reducing inflammation, and accelerating the healing process. Skin rolling can help release the scar’s attachment to deeper skin layers, while indirect myofascial release can help ease the nervous system through easing the scar’s pressure. Findings indicate that scar massage could be beneficial in reducing scar height, vascularity, pliability, pain, pruritus, and depression associated with hypertrophic burn scars.¹⁴

Splintage plays a crucial role in burn wound management. There are three types of splints usually used with burn patients: static, static progressive, and dynamic splints. Static or primary splints are used in the acute phase for skin graft protection after surgery or anti-contracture positioning. These splints are applied to adjacent intact skin. In addition, exercises are also vital for maintaining and improving the range of motion.¹⁵

Rationale for Treatment 

The rationale behind the treatment was that by releasing the tension on the volar surface of the index finger, we would be able to fully extend the finger, allowing for a full range of motion. A defect will be created on the volar surface that will be embedded with a full-thickness skin graft. A K-wire will be implanted into the finger for stabilization in the extended position to prevent finger flexion that may lead to loss of the skin graft. 

Procedure Details

A 1-year-old male infant presents with a volarly-flexed index finger around one year after suffering a burn to his index finger. The goal for the procedure was to release the contracture, insert a K-wire for stabilization, and place a full-thickness skin graft. The hand and distal forearm were exsanguinated to decrease bleeding during the procedure. An incision was made to the proximal index finger. Hooks and a 15 blade were used to retract additional skin. Careful manipulation of the skin and fascia was done in order to avoid damage to nearby neurovascular structures. Through the meticulous spreading of fascia using an Adson with teeth, the optimal release of the contracture was achieved. The exposed fascia was measured with a ruler to determine how much graft would be needed for the graft. The donor site was the groin crease. A scalpel and a snap were used to harvest the graft from the groin crease, followed by the removal of fat from the graft. Local anesthetic was applied to the donor site, followed by closure using 3-0 Monocryl for the dermal layer, and 4-0 for the subcutaneous layer. Dermabond was also applied. Before the K-wire was inserted, the index finger was cauterized to limit bleeding. For better control and stabilization of the wire, the performing surgeon choked up on the K-wire into the drill. The K-wire was inserted down the shaft of the index finger ending at the metacarpophalangeal joint, which inhibits any mobility of the finger. Since the release was near the metacarpal head, the K-wire was inserted in a way that would only allow the finger to move as one piece, which was confirmed after placement. Confirmation of adequate blood flow to the finger before and after K-wire placement was performed. Next, a 2/8 Jurgan ball was inserted at the tip of the K-wire to protect the tip of the finger. Next, the skin graft was applied using 4-0 chromic absorbable sutures. A nerve block to the index finger was administered to ease any pain when the patient wakes up. The decision to make the incision site above the old scar was made because the skin from the crease had been displaced distally, allowing him to give the patient’s hand more glabrous palm skin, which is important in a growing toddler. The surgeon covered the wound with Xeroform dressing, sterile gauze, and a plastic splint that held everything in place.

Special Considerations

Burn patients may face psychological and functional deficits secondary to skin contracture months or even years after the inciting event. Considering burn injuries rank third among injury-related deaths in children aged 1 to 9 years of age, special care is imperative.⁶ The pediatric populations have certain features that merit extra attention. Distinguishing features of children include the physiology of fluid and electrolyte handling, differences in energy requirement, and various body proportions, warranting a different treatment perspective than adults. It is proposed that if this special care is taken during the initial management, these children can better integrate into society.⁶  

Children, compared to adults, have a larger body surface area of the head and neck, relative to their overall body size. This difference should be considered when calculating the extent of the burn injury. Children have about three times the body surface area to body mass ratio of adults, therefore fluid losses are proportionally higher in children. This rapid fluid loss can lead to hypothermia, which should be avoided. It is known that children younger than two years of age have thin layers of skin and insulating subcutaneous tissue, predisposing them to hypothermia.⁶ To further add to the injury, temperature regulation in very young children is partially based on non-shivering thermogenesis, which consequently increases the metabolic rate, oxygen consumption, and lactate production even further.⁶ 

An additional consideration that needs to be made is the necessity of pediatric patient admission. Some indications for hospitalization include: partial thickness greater than 10% of body surface area, full-thickness burns greater than 2% of total body surface area, and burns involving the face, hands, genitalia, perineum, or major joints.⁶  

When fluid resuscitation is needed, special attention needs to be given to infants due to the higher metabolic rate, which is responsible for the increased amount of renal water loss. The Parkland Formula calculates how much fluid should be given to the burn patient over a certain period of time. For use in the pediatric population, Shriners Burn Institute made a modified version of the formula.⁶ 

Absolute contraindications for skin grafting include incomplete removal of cancer from the site, active infection, and uncontrolled bleeding.⁷ Relative contraindications include smoking, anticoagulant medications, bleeding disorders, chronic corticosteroid usage, and malnutrition.⁷  

Additional considerations for split-thickness grafts include avoidance of near-free margins due to the increased risk of secondary contracture. In respect to full-thickness grafts, they should not be used on avascular sites greater than 1 cm.⁷ In addition, special care must be taken not to injure the flexor tendons and neurovascular bundles on the radial and ulnar side of the index finger.

Discussion

Trauma causes many deaths around the world with burns wounds being responsible for most of these cases.¹ Our patient experienced a burn wound to the index finger approximately 1 year prior to seeking treatment and had noticeable hypertrophic scarring that led to contraction of the index finger in the flexed position. This finding was an indication for operative management to release the contracture and regain the full range of motion and functionality of the injured finger. K-wire insertion and a full-thickness graft were used to treat the patient.

Burn wounds lead to the disruption of the normal skin barrier that needs to be replaced, either with spontaneous healing or through the use of autologous donor sites.⁸  Skin grafts have been used since the 19th century and are recognized as the mainstay treatment for treating lost skin tissue.⁶  Split-thickness skin grafts have been the gold standard for such procedures, although there are many downsides to this technique such as the creation of a large wound, which contributes to increased pain, risk of infection, and scarring.⁸ Additionally, split-thickness grafts lack the necessary elements such as dermal fibroblasts, hair follicles, and sweat glands for proper wound healing.⁸ These factors lead to scar formation, skin contracture, and desiccation of the wound.

Comparatively, full-thickness skin grafts show less skin contracture and less scarring because they include the components for optimal wound healing. However, a disadvantage to full-thickness skin grafts is the requirement for rapid blood supply secondary to higher metabolic demand.⁸  The burn was in a sensitive aesthetic region; therefore, full-thickness skin grafting was preferred for this patient, as a secondary contraction would lead to significant functional deficits from a clinical perspective.

Aside from conventional skin grafting techniques, modern medicine for burn wounds has shown significant progress in the last 10 years. With advancements in the field of regenerative medicine, biologic agents have shown promising results. The immune system plays a major role in the healing process of burn wounds, thus providing a target for treatment. Immune-based therapies include macrophage-activating-lipopeptide-2 (MALP-2) and platelet-rich plasma gels to resolve chronic burn wounds.⁹ Varying levels of success in clinical trials have been shown with transforming growth factor-B1 (TGF-B1), interleukin-10 (IL-10), mannose-6-phosphate (M6P), and nefopam for scar prevention.⁹

According to Larouche et al.9, TGF-B1 has shown to decrease scar size in both phase I and II clinical trials, although full regeneration was never seen. Furthermore, TGF-B1 therapy in the early stages of wound repair accelerates wound healing consisting of self-limited recruitment of immune cells, which is followed by cellular proliferation and re-epithelialization. However, once the remodeling phase has taken place, TGF-B1 therapy can lead to increased scar formation.

The development of a newer and cost-effective treatment is possible. Genetically modified porcine skin [alpha-1, 3- galactosyltransferase knockout (GalT-KO)] can become an easily accessible xenograft in the near future. This advancement has been shown to have a similar tolerance to fresh or cryopreserved allografts. Apligraft is a type of “complete” graph that contains epidermal and dermal elements and has shown to improve cosmetic and functional outcomes compared to an autograft.¹⁰ 

Although this paper mentions the ongoing research for new options for burn treatment, there are a number of treatment options in clinical trial phases. With new methods that are being discovered every year, the decrease in complications and psychological distress will reduce the morbidity and mortality of burn injuries, overall improving the quality of life of patients.

Equipment

K-wire, K-wire inserter, cutter, bender, splint.

Disclosures

Nothing to disclose.

Statement of Consent

The parents of the patient referred to in this video have given their informed consent for surgery to be filmed and were aware that information and images will be published online.