B Sreekanth Rao¹, T Zeeshan Muzahid^2*, M Venkaiah³, TVG Krishna⁴, GVS Moorthy⁵

¹Associate Professor, ²Assistant professor, ³Assistant Professor, ⁴Associate professor, ⁵Professor, Department of Orthopaedics,

Bhaskar Medical College and Bhaskar General Hospital, Yenkapally, Telangana, INDIA.

Email: bsreerao@gmail.com  

Table I: Age and Sex distribution.

Table II: Age and Time since injury / burns.

Table III: Number of Digits and Web spaces involved

Table IV: Wrist and Elbow requiring spanning External Fixator

Table V: Types of Fixation and Duration of treatment

Table VI: TAM Score

Table VII: Pre-Operative and Post Operative Functional Capacity.

Table VIII: Psychological improvement.

Figure 1: CONTRACTURE RELEASE, K -WIRES IN FINGERS, EASE OF DRESSING

Figure 2: CONTRACTURE HAND and ELBOW, EXTERNAL FIXATOR WRIST and ELBOW, EASE OF DRESSING, PHYSIOTHERAPY, FUNCTIONAL IMPROVEMENT

Figure 3: CONTRACTURE WRIST, EXTERNAL FIXATOR WRIST EASE OF DRESSING, FUNCTIONAL IMPROVEMENT

DISCUSSION

The world literature documents external fixation and distraction for extremities as an established modality for management of severe contractures following post burn and traumatic injury.^5,6External fixation involve the use of percutaneously placed transosseus pins and wires secured to external framework to provide support to a limb and joint. The benefits of external fixation are numerous. When compared with internal plates and intramedullary nails, external fixators cause less disruption of the soft tissues, osseus blood supply, and periosteum.⁷ Unilateral frames allow the limb to remain functional, avoid complications, and provide bony stability.⁸ Knee flexion and extension contractures as well as ankle equines contractures have been successfully corrected with a gradual technique using a simple hinge construct.^9,10 The most common risk after contracture release, despite adequate occupational therapy is recurrence. It is for this reason we utilize dynamic distraction external fixation.¹¹ The upper limb is viewed as a mechanism to place the hand in space where it is needed to perform necessary functions. The function of a normal hand is grossly limited if active elbow flexion is absent. Lack of active elbow extension may result in an inability to stabilize paper on a desk with one hand to write with the other.¹² Joint contractures are a common complication of hand trauma and can have several causes related to contractures or adhesions of the tendons, thickening of the synovium, contracture of the ligaments or joint capsule, insufficient skin cover or scarring and bone block or exostosis within the joint.¹³ By distraction straightening, the principles of a gradual dynamic lengthening of the skin and soft tissues are applied. All tissues get stretched out, thus maintaining a sensate pliable skin cover.¹⁴ Muscles produce force and movement and these properties can be adversely affected by contracture and contracture treatment. Therefore treatment should therefore be directed to maintain to increase contractile and connective tissue length whilst reducing stiffness and loss of elasticity. Muscle properties of force generation should be “normalized” through treatment.¹⁵Skin grafts and soft tissue procedures for the elbow and wrist can be testing, at times they do not take in when there is immoderate motion. Immobilization of these joints with the simpler splints may not be a better choice, as the surgical sites would need regular monitoring and wound care. We believe that in splints along with motion there can be wound soakage adding to infections and complications leading to disorganised graft incorporation. This study is a small case series to offer this as a technique and treatment option on post traumatic and burns contractures injuries of elbow, wrist and, hand. Evaluated and treated by contracture release, split skin grafting, the placement of a spanning external fixator, kirshner wires. This study we demonstrated that spanning external fixation, kirshner wires is an applicable option to treat these injuries. In this study all the procedures were done under general anesthesia, no tornique was used. we used kirshner wires to immobilize the finger joints after release of contractures and correction of deformities, split skin grafting done over the raw areas, secured by 3.0 silk sutures. Web spaces contractures were also attended with contracture release and split skin grafting, here to maintain the abduction between the fingers we kept cut latex glove fingers filled with water and sealed. In cases of wrist and elbow contractures after releasing of contractures and correcting the deformities external fixators were spanned across the joint. This procedure was very economic kirshner wires, external fixator easily available least expensive can be removed with ease not needing anesthesia /operation theatre charges. External fixators connecting rods and clamps can be reused after autoclaving especially in patients who cannot afford, it is like a blessing in disguise. Dressings could be changed with ease. Never needed the expensive separators between fingers as we used the least expensive easily available latex gloves and filled with water. They were very playful for the children and welcomed it with happiness. Surgery to achieve active movements in these patients to enhance function, requires committed patient compliance with treatment for retraining of the muscles used to achieve the active movements. We could win their trust, in return we motivated them throughout the period of treatment through physiotherapy rehabilitation. In all the patients post-operatively there was no neurological deficit. Donor site had no complications. After the removal of fixations patients were subjected to physiotherapy under supervision were followed for 6 months to one year. It helped them gain anatomical alignment, functional range of movements in with results ranging from good to excellent.

CONCLUSION

We found that orthopedic devices are an excellent tool in the equipment of the surgeon to treat the burn, trauma joint deformities. Every patient is very different, so treatment must be modified to match the clinical observations. Consistent postoperative motion and therapy remains essential for successful outcome. The crucial key is motivated, compliant patients and their parents. The functional and stunning excellent results of these procedures, was supplemented with physiotherapy rehabilitation. It has advantages that it allows regular wound inspection without change in position and useful especially in children where it is difficult to maintain the position of joints by the conventional methods. The least cost, low distress, ease of wound care, psychological booster and minimal complications make this an alternative to the other techniques used, either as the first line therapeutic treatment option or as a last hope when other techniques have crashed. The functional, cosmetic and psychological results of this approach of treatment are exceptionally satisfactory. It was very economical pocket friendly, minimally invasive technique to treat the contractures across hand, wrist and elbow joints treated in semi-urban population.

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