24 Plastic & Reconstructive Surgery

BURN SCAR CONTRACTURES & THEIR MANAGEMENT

K Walsh, D Nikkhah, B Dheansa

Burn scar contractures & their management

Plastic & Reconstructive Surgery
The LD50 (the lethal dose of burn in 50% of the population) in 1950 for a 21
year old was 40% total body surface area (TBSA), but now that figure is 90%.
This is due to improvements in the management of a burn injury (first aid,
fluid management, antibiotics, intensive care and surgery) (1). However, the
LD50 in the elderly population remains much lower at 40%. This is related to
other co-morbidities, longer hospital stay, poor wound healing, predisposition
to sustaining deeper burns as the skin is thinner and first aid may be limited
if they live alone.

Abstract
In this article we discuss the different surgical approaches to burn scar
contractures. Burn scar contractures can lead to a poor functional and cosmetic
outcome as well as possible psychological consequences. We describe the
benefits and complications of the different modalities of treatment. By the
end of this article the core trainee should be able to describe the different
types of management options for preventing and treating burn contractures.
Once a patient has been resuscitated, efforts are then made to improve
wound healing in order to prevent scarring and contractures. Contractures
lead to a loss of function, poor cosmetic outcome, reduced quality of life
(QOL), pain and psychological consequences (3,4). Function is determined
by 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. Contractures of the neck, axilla and hand
are shown in figures 1-4.

Keywords: burn, scar contracture.

Case Report
A 7 year old male presented to hospital with a 2% burn over his right
elbow due to a scald from boiling water. No first aid was applied when
the injury happened 2 hours previously. The burn was mixed in depth but
examination revealed the wound did not blanch, was not painful and was
pale in appearance indicating a dermal burn. In the following days a split
skin graft was performed along with the application of a splint. With active
physiotherapy over the course of 6 months, the range of movement was
normal with minimal scarring.

Introduction
Burns constitute the second highest incidence of trauma related deaths
globally, second to vehicular trauma (1). Within the U.K 250,000 burn injuries Figure 1: A thick linear contracture band
occur each year in which 1000 people are admitted to hospital and 300 of the neck and peri-orbital contractures.
patients die (2).

The most common mechanism of injuries are scald and flame burns,
accounting for 45% and 20% of burn injuries respectively. Flame burns
usually result in an increased depth of burn. Chemical and electrical burns are
less prevalent (<10%) (2).

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BURN SCAR CONTRACTURES & THEIR MANAGEMENT
Figure 2: Axillary contracture. Axillary contractures greatly reduce the
range of abduction, flexion and extension of the shoulder. Release of
axillary contractures greatly improves the quality of life for such patients.
Figure 3 and 4: Contractures of the Hand. Contractures of the palmar
aspect of the hand form fixed flexion deformities. Figure 3 shows a
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 Interphanageal Joint. Figure 4. Contracture
along the dorsal aspect of the thumb and the webspace between the
dorsal aspect of the thumb and index finger limit the ability to form
a tight fist and grip.
Plastic & Reconstructive Surgery 25
K Walsh, D Nikkhah, B Dheansa
Figure 4.
Pathophysiology of Scars and Contracture
Superficial partial thickness burns rarely lead to scarring. Conversely, deep
dermal or full thickness burns extend to the dermal reticulare, which destroys
the epidermal appendages and their extensions into the dermis. The wound
is less able to spontaneously epithelise and wound closure occurs from just
the wound edge rather from the central portion of the wound (1,5). This
leads to a delay in wound healing which increases the risk of scarring.
Deep dermal burns may lead to hypertrophic scarring. Peacock defines
hypertrophic scarring as: ‘a scar raised above the skin level that stays
within the confines of the original lesion’ (1,6). There is an over-proliferative
response of wound healing leading to excessive deposition of collagen and
ground substance. Collagen type III is the predominant connective tissue type
and is structurally disorganised and nodular (7).
Myofibroblasts proliferate at a wound site which causes the wound edges
to contract towards one another. Delayed healing and scar formation leads
to an over-proliferation of myofibroblasts causing pathological contracture.
Hypertrophic scars usually occur within the first three months of a burn
injury. Dietch et al. concluded that one third of anatomical sites became
hypertrophic if the healing time occurred between 14-21 days. After 21 days,
78% of scars became hypertrophic (8). Recognised factors which may delay
wound healing include infection, smoking, supressed immune system, age,
poor circulation and nutrition. Such factors may delay wound healing causing
breakdown of the wound.
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26 Plastic & Reconstructive Surgery
BURN SCAR CONTRACTURES & THEIR MANAGEMENT
K Walsh, D Nikkhah, B Dheansa
The incidence of pain and pruritus are common during scar formation.
These symptoms are both distressing for patients. Unfortunately, the exact
pathophysiological causes for these symptoms have not been elucidated.
It hypothesised to be due to histamine or kinin formation activating C-fibre
nociceptors (5).
Scar and Contracture Assessment
The Vancouver Scar Scale (VSS) is one method to measure scars (as shown
in Table 1). The VSS attributes scar contractures with a score indicating a
poor outcome of scar development (9). The VSS is widely used, although it
is widely known to lack reliability and there are issues concerning observer
variability. VSS does not also rate itching or pain (10). A scar should be
reviewed in clinics and the VSS score should be recorded to see whether
the scar deteriorates.
Table 1.
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Burn scar contractures & their management
Plastic & Reconstructive Surgery
Vancouver Scar Scale
Assessment of a contracture should begin with documenting the area and the
characteristics of the contracture. These include its laxity, whether it is linear
or a plaque and if the surrounding skin is burnt or scarred. Timing of surgery
is dictated by whether the surgery is an emergency. For example areas
which may limit the patient’s airway: the neck or tissues surrounding the
mouth. Contractures at the axilla require urgent release as they can quickly
lead to debilitating function of the shoulder, particular limiting the range of
abduction. Priority should also be given to proximal structures compared to
distal structures. There is no point releasing a web-space, if the patient is
unable to move their entire upper limb due to an axillary contracture (11).
A history should be taken to determine problems involving self-care, social or
work related problems. For example, a patient may be unable to bring their
hand towards their mouth in order to eat and subsequently would benefit
from surgery.
Prevention of Burn Contractures
It is far better principle to prevent contractures rather than treat them. Major
burn cases have declined due to improvements in health and safety at work
and domestically (12). First aid is vital to prevent burn extending deep into
the dermis. First aid should include removal of clothes at the site of burn,
placing the injured site under a tepid tap of water for a minimum of 20
minutes and wrapping the site in cling film. Upon admission, burns should be
assessed to gauge the size, the depth of burn and the mechanism of injury.
This is a priority but unfortunately burns are not always assessed sufficiently.
One study showed 30% of patients performed appropriate first aid and
furthermore74% of burns upon admission were not assessed adequately (2).
Laser Doppler Imaging (LDI) is used to determine the blood flow at the burn
injury site. This provides an accurate description at the depth of the burn. It is
a useful aid to deciding when a burn will likely heal. LDI is used between 2-5
days following a burn injury.

BURN SCAR CONTRACTURES & THEIR MANAGEMENT
A clinician should determine from their assessment if the burn is likely to
heal before or after 21 days. Cubison et al. concluded that there is a low risk
of hypertrophic scarring if the burn healed conservatively before 21 days.
Only intermediate burns that are expected to heal after 21 days were likely
to develop a hypertrophic scar should receive primary excision and skin graft.
Burns expected to heal before 21 days may be dressed with Biobrane, skin
allografts or with simple dressings. Biobrane is a biosynthetic silicon dressing
which contains an embedded sheet of nylon. This is left on the wound and
provides the wound with a 3D structure to heal to. The nylon sheet causes
blood and sera to clot forming a firm dressing (13). Cadaveric allografts
provide temporary closure of the wound. Such allografts behave like normal
skin but are rejected may require replacement. Application of such dressings
help to prevent early desiccation, prevent infection, reduce loss of water or
proteins and electrolytes.
There is general agreement that major burns should be treated with
aggressive excision and skin grafting. Split skin grafts (SSGs) should only
be reserved for burns likely to heal after 21 days (5). Large burns require
multiple operations and areas should be prioritised. Potentially, early excision
and skin grafts will be delayed at certain sites, leading to prolonged healing
time and scarring. Also, the total amount of skin available for a graft should
be determined. A shortage of skin will require the use of a mesh graft as
opposed to a sheet split skin graft. A mesh graft however will contract greater
than a sheet SSG.
Schneider et al. concluded the importance of therapeutic positioning and
intensive therapy intervention. The study of 985 patients concluded that
38.7% of patients developed a contracture at hospital discharge. The shoulder
was the most common joint to undergo contracture (38%), followed by the
elbow (34%) and the knee (22%) (14).
Following a burn injury over the surface of a joint, splintage should be used to
place a joint in a position which will later allow a patient to maintain essential
function e.g. eating, drinking, going to the toilet. There are a wide range of
splints which stretch the skin and maintain positions of function (12, 15, 17).
Burns to the flexor surface of the skin increase the risk of contracture as the
flexor muscles are stronger than the extensors. Full co-operation is essential
for reducing long term pain, providing a greater range of movement and
reducing the requirement for further surgery.
Physiotherapy is important to prevent scar formation and limit contractures.
Celis et al. showed that patients receiving additional, supportive physiotherapy
required less surgery for burn contractures than a group receiving basic
support (16). Adequate analgesia alongside patient education is a priority
as patients must move their affected joints despite perceived pain (14, 17).
Plastic & Reconstructive Surgery 27
K Walsh, D Nikkhah, B Dheansa
Early Scar and Contracture Management
• Medical Options
There are lots of methods for early scar management. Splintage and
physiotherapy, described previously, are incorporated into early contracture
management. Physiotherapy should be goal orientated and suit the individual
needs e.g. going back to work or to be able to perform everyday tasks (17).
Splintage and physiotherapy are used following surgery for contracture release.
Moisturising and massaging the wound improves pliability of the scar,
particularly if the scar is dry and uncomfortable. Corticosteroid injections are
also used to treat scars. 1mg of steroid is injected at sites 1 cm2 apart. Steroid
injections take place every 6 weeks.
Other forms of therapy include: application of silicone gel, wearing pressure
garments and the use of a laser to reduce scars. Such methods are
controversial as there is a plethora of literature which supports or refutes the
effectiveness of each of these treatments.
Surgical Options
• Local Surgical Procedures
The Z-plasty is a commonly used local procedure for contracture release and
mainly used for bowstring contractures (11,12). The Z-plasty borrows skin
from adjacent tissue sites to divide and lengthens the contracture band. As
there is shortening within the transverse axis, there may be little room for
further shortening with a z-plasty. A multiple z-plasty may be preferred as
theoretically this reduces transverse shortening. The z-plasty should only
really be used when there is ample laxity of the surrounding tissue and not
in diffuse contractures.
The Y-V plasty (figure 5) is relatively simple to perform and is recommended
for linear bands. In comparison to the Z-plasty, the Y-V plasty does not require
undermining, which reduces the risk of distal tip necrosis. Contractures can be
lengthened by 100%, whereas with a 60 degree Z-plasty, length is increased
by 75%. The Y-V plasty can also be repeated adjacently which is used when
there is a broad sheet of contracture. Patients are able to mobilise earlier
post-operatively than if the Z-plasty was chosen. Other techniques include,
the double reverse V-Y plasty and the W-plasty (11,12) (figure 6).
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28 Plastic & Reconstructive Surgery
BURN SCAR CONTRACTURES & THEIR MANAGEMENT
K Walsh, D Nikkhah, B Dheansa
Figure 5. The V-Y plasty.
Figure 6. The W plasty.
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Burn scar contractures & their management
Plastic & Reconstructive Surgery
• Flaps with and without tissue expanders
Free, local and fasciocutaneous flaps have been used to treat contractures
which limit the range of movement greater than 50%. Flaps are mainly
used for broad sheet contractures. Within the upper limb, regional flaps
include; radial forearm fasciocutaneous flap, posterior interosseus artery flap,
latissimus dorsi flap or a propeller flap (12, 18, 19, 20). Often the scar tissue
can be used as part of the flap, however there is a potential risk of a poor
cosmetic outcome and diminished elasticity.
There are difficulties with the use of a free flap. A free flap is limited by the
amount of skin taken from a donor site. This donor site would require a SSG
which could potentiate contracture. Dissection of recipient vessels to connect to
the flap is difficult due to the distortion of tissue from the scar. Free flaps require
tissue to be imported which is of a different colour, bulk and texture (11). This
is can be overcome with the use of skin expanders however there are risks of
infection, skin ischaemia or leakage (11). In addition, the areas where tissue
expansion can be limited, particularly if the surrounding area is burnt.
 Plastic & Reconstructive Surgery 29

BURN SCAR CONTRACTURES & THEIR MANAGEMENT

K Walsh, D Nikkhah, B Dheansa

• Skin Shortage
In comparison to full thickness skin grafts (FTSGs), split skin grafts (SSGs)
are easily harvested, can cover a larger area, release multiple joints and
broad sheet contractures. Unfortunately, SSGs are prone to form hypertrophic
scarring and further contracture of the wound site (1,5,11,12,14,17). If the
burn is large, a meshed split skin graft will lead to a greater degree of contract
than a sheet SSG. FTSGs have less contracture due to more dermis within the
graft. Conversely their take is dependent on a richer vascular bed (4,11). In
recent years SSGs have been incorporated with dermal templates.

Dermal templates consist of a bovine collagen matrix with an overlying

silicone sheet. Artificial skin substitutes lead to a reduced inflammatory
reaction and consequently reduced contracture. There are mixed reports of
their effectiveness at preventing contracture. Soejima et al. has reported
that in 75% of cases a good cosmetic outcome had been achieved with a
reduction in scar hypertrophy. However, Hunt et al. reported a high incidence
of re-contracture when dermal templates were used during neck contracture
release (11, 21, 22). Summary
• Surgical Planning After reading this article, the core trainee should be able to:
Large burns incorporate multifactorial obstacles such as a loss of function
to numerous joints and severe deformity. The surgeon should formulate 1) Understand the importance of adequate clerking of a burns patient
an organised plan for the entire rehabilitative process. The surgeon should 2) Be able to understand the pathophysiology of burns contracture
prioritise the order and time scale of surgical procedures so an earlier 3) Understand that the most important management
operation does not complicate future surgical procedures. Poor planning may of burns contracture is prevention
delay the rehabilitative process. This subsequently delays when a patient is 4) Assess a contracture
able to return to work or be able to support themselves. Also, one must think 5) Understand the principles of managing a burns contracture
of the cost effectiveness when planning the number of operations required.
Multiple operations may also need to be planned for the same time. The Q&A
surgeon should also be receptive to the patients’ needs. A scar contracture at
one joint may be more of a priority to a patient than the surgeon. This should 1) What is the most common mechanism of burn in the UK?
therefore be considered and the surgeon should be flexible in their plan for
the patients’ needs. A) Chemical
B) Electrical
Table for the Complications of Varying Treatments C) Scald
D) Flame
E) A cold burn

2) What period of healing time is associated with

the highest rate of hypertrophic scar formation?

A) 0 Day
B) 14 days
C) 21 days
D) 25 days
E) 30 days

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30 Plastic & Reconstructive Surgery
BURN SCAR CONTRACTURES & THEIR MANAGEMENT
K Walsh, D Nikkhah, B Dheansa
3) What is the main disadvantage of a Z-plasty
for the treatment of a contracture band?
A) A complication is ischaemia of the tip of the wound
B) Poor cosmesis
C) Recontracture
D) Requires flattening through physiotherapy
E) Z-plasty does not dissect through the contracture
band as well as a Y-V band
4) Which is not a principle of contracture removal?
A) A free flap is preferable to a skin graft
B) The distal joint should always be released before the proximal joint
C) Important underlying structures may need to be exposed
D) Each joint should be considered separately
E) Function should take priority over cosmesis
Answers
1) C
2) E
3) A
4) B
Note: Written consent was obtained for figures 1-4.
Acknowledgements: Kate Murrell designed figures 5 and 6.
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Burn scar contractures & their management
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BURN SCAR CONTRACTURES & THEIR MANAGEMENT

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