54 Bums (1992) 18, (l), 54-57 P&fed in Greaf Britain

Management of burn contractures of the first web

space of the hand

S. Bhattacharya, S. K. Bhatnagar, S. D. Pandey and R. Chandra

Postgraduate Department of Plastic and Reconstructive Surgery, King George’s Medical College, Lucknow, India

Fivsf web spuce contracfures of the hand uffecf predominantly the

mouemenfs af the trupeziomefacarpaljoinf, rendering the thumb ineffecfive
for opposition and thereby destroying the essential elements of grasp and
pinch. Adequate release of confracturedfirst web space followed by a local
skin flap cover and dynamic abduction splintage for the subsequent 6 weeks
gives excellent results. Documenting thefirst web angle at every follow-up
visit can defect early recurrences and the dynamic splintage can be
reinstituted fo achieve the normal first web space. Secondary surgery in the
form of flexor pollicis longus tendon lengthening or opponens-p&y helps
to prevent recurrences.

Introduction
Figure 1. An extensive partial skin thickness bum of the hand
The thumb by virtue of its unique mobility at the trapez-
with involvement of the first web space.
iometacarpal ‘sellar’ joint - stability being rendered by
intrinsic muscles - and a relaxed cutaneous and supple
muscular web, ensures a variety of prehensile and manipula-
tion movements, thereby enhancing considerably their 0 Clinical - by a goinometer (Fritschi, 1971).
accuracy and precision. First web space contractures result- 0 Radiological - angle between the longitudinal axes of
ing from bums, which have been improperly managed, the first and second metacarpals compared with the
perhaps without proper splintage or timely surgical inter- normal hand using an identical view.
vention, may limit the movement of the thumb, thus 0 Stent mould angle - dental material (stent mould) was
affecting both grasp and pinch. If contractures affect the softened in boiling water and packed into the first web
dominant hand, as they do on most occasions, the vocation space with the thumb in maximum active palmar
and thereby the economic status of the patient suffers. abduction. It was allowed to set and the web space cast
Proper management of this deformity is thus highly so obtained was sectioned sagitally across the web. Its
desirable. two cut surfaces were smeared with ink and two
impressions from each obtained on a paper. The irregular
Materials and methods borders of thumb and index finger were replaced by
straight line tangents and the angle between them
The study was conducted on 34 hands which had estab-
measured (Bhattacharya et al., 1989).
lished first web space contractures with degrees of motion
(palmar abduction) of 0” to 34” and 14 freshly burned hands, The 14 hands in the prophylactic group (Figure Z) were
which if not managed properly, had the potential for managed by static or dynamic splintage, active and passive
developing gross contractures and deformities. During the exercises and timely surgical intervention using de-
same time interval eight previously treated first web space bridement and skin grafting. Static splint-age was provided
bum contractures were also evaluated and they formed the by plaster of Paris spacers or stent mould spacers and
retrospective group. The established contractures were dynamic splintage was given by a dynamic abduction splint
between 7 months and II years old. After treatment the designed in our unit (Figure 2) (Chandra et al., 1986). The
patients were followed up for periods of between 4 months period of follow-up of these patients ranged between 4
and 3 years. months and 3 years.
A detailed clinical examination in each patient was An established first web bum contracture (Figtrre 3) was
followed by documentation of the first web angle. Three released stepwise from the skin down to the apex of the first
different methods were employed. web space, from hinge to hinge, until the intermetacarpal
0 1992 Butterworth-Heinemann Ltd
0305-4179/92/010054-04
Bhattacharya et al.: Bum contractures of first web space of hand
b
Figure 2. A hand with a first web space contraction (a) and a
dynamic splint in position on the same hand (b).
Figure 3. A postburn contracture of the first web space asso-
ciated with the contracture of the dorsum of hand.
angle became 40” and the angle of the web approximately
90”. In 29 out of 34 hands this was possible by releasing only
the skin and excising the subdermal fascial plaque. In the
remaining five hands release of I dorsal interossei and
adductor pollicis was also required.
The released status was maintained by an inter-metacarpal
K-wire fixation which was replaced by a dynamic abduction
splint after 2 weeks (Figure lb).
The raw area which resulted from contracture release was
covered by:
Split skin grafting in six patients
Local flaps in 15 patients, and
Distant flaps in 13 patients.
The various local and distant flaps used for coverage are
listed in Table I. Other associated contractures, mostly
55
c
Figure 4. a, The postburn contracture of the dorsum of hand has
been released and covered by a distant flap which in turn has been
detached from the donor site. Note the first web space contracture
which will now be released. b, After releasing the first web space a
K-wire is being used to produce intermetacarpal fixation. The flap
used to resurface the released dot-sum of hand is also seen. c, The
released first web space has been covered by the pcdicle of the flap
used to cover the dorsum of hand.
contracture of the skin of the dorsum of hand resulting in
clawing and flexion contractures of wrist, were commonly
encountered. Whenever there were multiple contractures
the wrist or dorsal skin contractures were released at the first
operation and covered by distant flaps and the first web
space contracture was released in the next operation, the
pedicle of the same flap being used to resurface it after
severing it from the donor site (Figrdres4, 5).
A fortnightly follow-up for the first 3 months and a
monthly follow-up for about 1 year thereafter was arranged
and on each occasion a fresh stent mould angle was
56
Figure 5. The released bum contracture of the dorsum of hand
has been covered by a subaxillary flap. Note the associated
adduction contracture of the thumb which will be released at the
next operation and the pedicle of this flap will be used to cover the
released first web space.
obtained. When this angle reduced to 70” from the corrected
status (of 90” approximately),as was seen in the six patients
in whom the newly created web was covered by split skin
graft, dynamic abduction splintage was started again.
Secondary surgery was required in three patients,
opponens plasty in two and Z lengthening of flexor pollicis
longus tendon in one.
Table I. Local and distant flaps used for coverage
No.
Local flaps
Z-plasty (McGregor, 1957, 1967)
Four flap Z-plasty (Wolf and Broadbent, 1972)
Double Z-plasty with Y V advancement
(Hirshowitz et al., 1975)
Dorsal thumb flap (Strauch, 1975)
Radial a. forearm flap (Yang and Gao, 1981)
Distant flaps
Groin flap (McGregor and Jackson, 1972)
Abdominal tube pedicle
Lateral thoracic region flap <A>
Subaxillary fasciocutaneous flap < 6 >
Burns (1992) Vol. 18/No. 1
Results
All the 14 freshly burned hands recovered and periods of
follow-up between 4 months and 3 years showed no
functional loss serious enough to demand a change in
vocation. There were no contractures and the first web
space, in each of them, was supple and wide allowing the
thumb to perform effective pinch and grasp.
In the established contractures the scarred skin and the
fascial plaque at the level of subcutaneous tissue were the
commonest aetiological factors of restricted mobility and 29
out of 34 thumbs could be brought to 90” palmar abduction
by only incising the skin and then excising the plaque. The
next step of muscle release was required in five hands. The
muscles adductor pollicis and I dorsal interossei were supple
and responded to electrical stimuli.
The following observations were made at follow-up of
the 34 established cases:
Split skin grafts on the first web had an inherent
tendency to contract and hence recurrence of contracture
is common (Figure 6). They required prolonged periods
up to 3 months of immobilization as compared to webs
covered by flaps of full thickness skin.
Stent mould angle could pick up the recurrence earliest
and splintage was thus reinstituted at a very early stage.
Secondary surgery was required in three patients -
opponens plasty in two and Z lengthening of the flexor
pollicis longus tendon in one. These prevented recur-
rences and improved hand functions.
The retrospective study of eight hands previously treated
for their first web bum contracture revealed that:
??The contracture was released up to the level of skin and
fascia in all eight patients.
??Coverage was provided by split skin grafting in five,
local flaps in two and a groin flap in o&hand.-
0 All webs covered by split skin grafts showed some
recurrence of their contracture and three of them
required secondary surgery.
??In one hand the Z plasty was opened and adductor
tenotomy and first dorsal interosseous release were
carried out to open up the web, and in another an
opponens plasty was required to improve thumb
function.
Discussion
As we move away from the axis of abduction the contrac-
tion effect of the tissues in the first web space increases
Figure 6. Recurrence of both dorsal contracture of the hand as
well as first web space conkacture 6 months after release and split
skin grafting.
Bhattacharya et al.: Bum contractures of first web space of hand
because of a longer lever arm. Therefore the skin and t-he scar
at the subcutaneous level causes maximum contractural
effect. The underlying muscles and joint capsule are rarely
injured.
Most of the severely contracted thumbs at some time or
another had passed through a stage when they were either
totally preventable or arrestable before a stage of gross
disfigurement. By proper splintage, physiotherapy and
timely surgery, whenever needed, adduction contracture
can be totally prevented. Littler (1959) also emphasized the
role of this preventive treatment and Fritschi (1971) demon-
strated the exercise of thumb web stretching between the
shaft of the first and second metacarpals.
For documenting the dimensions of the first web space
linear distances between surface landmarks in thumb and
index finger or palm, as proposed by Meyer et al. (X981),
Flatt and Wood (1970), Boyce (1971) and Comtet and
Bemelmans (1979), can never be accurate because they do
not take the laxity of the metacarpophalangeal joints into
consideration and because they indicate a linear distance and
not an angle. Stent mould angle measurement, which we
have applied for our follow-up studies, is the best method
for the documentation of the first web angle (Bhattacharya
et al., 1989).
Mutz (1972) suggested that the web should be released
only when the intermetacarpal angle reached 35--JO”, as it is
at this angle that the thumb and index finger spread by 90”.
A release beyond this would produce an abnormally long
and obtusely protruded thumb, cosmetically poor and
functionally no better.
For covering the web sensory local flap cover (which is a
one-stage method) is ideal, but often because of extensive
scarring of the surrounding area, it is not available and a
distant flap has to be used. The contralateral chest wall, the
lateral thoracic region flap (Bhattacharya et al., 1990) and the
subaxillary flap (Chandra et al., 1988) have concealed
inconspicuous, non-hairy donor areas, which can often be
primarily closed. They have excellent vascularity, and as the
hand is kept in a non-dependent position postoperative
oedema is minimal.
If a first web space contracture resulting from bum injury
can be adequately released, split skin grafting of the web
avoided and flap cover provided, dynamic abduction splint-
age for the subsequent 6 weeks instituted and secondary
surgery carried out whenever indicated, such deformed
hands can again be made functional and effective vocational
training and rehabilitation can make these patients useful
members of society.
References
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Paper accepted 5 August 1991.
Correspondence should be addressed to: Dr S. Bhattacharya, C-907,
Mahanagar, Lucknow, 226 006, India.