Indian Journal of Burns

GURU SPEAK
Year
: 2021  |  Volume : 29  |  Issue : 1  |  Page : 4--6

Tips for management of postburn neck contracture


Parmod Kumar 
 Department of Plastic Surgery, PGIMER, Chandigarh, India

Correspondence Address:
Dr. Parmod Kumar
Department of Plastic Surgery, PGIMER, Chandigarh
India

Abstract

Postburn neck contractures are frequent sequelae after deep thermal burns. They are a significant cause of morbidity and pose a serious challenge for anesthesia. In developing countries, lack of adequate burn care infrastructure, training, and workforce leads to the occurrence of multiple postburn deformities. Wound healing can never occur without wound bed contraction. Therefore, the best treatment for any problem related to burn wound contraction is to prevent or at least reduce its severity. The same is the case with postburn contractures and deformities. The use of simple measures can prevent or at least limit the severity of deformities even when used by trained paramedics and nursing staff.



How to cite this article:
Kumar P. Tips for management of postburn neck contracture.Indian J Burns 2021;29:4-6


How to cite this URL:
Kumar P. Tips for management of postburn neck contracture. Indian J Burns [serial online] 2021 [cited 2022 Sep 27 ];29:4-6
Available from: https://www.ijburns.com/text.asp?2021/29/1/4/346911


Full Text



 Introduction



Burns constitute a major health problem in India. The burn injuries have been estimated to the tune of seven million cases annually. They cause 1.4 lakh deaths each year and burn survivors end up with 1.7 lakh burn-related disabilities annually.[1] There is a lack of dedicated burn centers in peripheral health centers, so burn patients are managed by general physicians and sometimes untrained staff with dressings only.

 Morbidity of Postburn Contracture Neck



Burn wounds in majority of patients heal by secondary intention leading to the formation of contractures and various deformities. Major burn injuries commonly have neck burns. Deep burns in the thin mobile neck skin in the absence of proper treatment lead to postburn neck contracture. It causes significant morbidity [Figure 1], [Figure 2] as it:{Figure 1}{Figure 2}

Limits erect posture, thus affecting the field of vision, feeding, and other activities of daily livingCauses secondary contracture of lip, chin, and face leading to oral incompetenceLimits movement of rib cage leading to poor chest expansion during respirationLimit bone growth of cervical spine and mandible in growing children leading to severe skeletal deformitiesSeverely limit the access to airway for elective or emergency endotracheal intubation.

 Principles of Management



Majority of postburn neck deformities are preventable. Care under a dedicated burn team is needed for this. It helps to preserve, restore, and maintain function. The principles which need to be strictly adhered to include:

Proper positioning of the neck in straight and slight extensionEarly initiation and regular physiotherapy with a range of motion exercisesEarly wound closure with skin graftingUse of proper fitting splint to maintain cervico-mental angle and provide gentle pressure over healed or grafted burn woundScar care with a massage using moisturizers and emollientsUse of silicone gel sheeting and custom-made pressure garments till scar maturation.

 Tips For Management of Neck Burns and Contracture



Proper treatment of neck burns not only prevents deformities but also significantly reduces the morbidity of the patient. Various techniques under an algorithmic approach have been described for neck contractures.[2] I am sharing a few tips that I have learned in the past 15 years. It will help burn surgeons and other members of burn team to achieve better outcomes in burn patients, especially with respect to neck burns and associated deformities.

In the acute stage, during dressings, we prefer to educate and motivate patients and caregivers with video demonstrations on mobile phones about positioning and range of motion exercises. Our physiotherapist and nursing staff help us in this aspect. We advocate the use of a thin pillow under the shoulder and a doughnut-shaped roll of cloth under the head to maintain position. We provide custom-made neck splints cushioned with foam to patients to improve compliance. Early wound debridement and skin grafting to achieve wound closure before 21 days of burn injury is targeted in each case. The airway needs proper assessment by anesthesia team so as to avoid complications. Operative technique involves proper positioning of a patient under anesthesia with padding under the shoulder and multiple head rings or layered sheets under the head [Figure 3]. The contracture bands should be kept taut by sequential removal of head rings and cut with a gentle pressure of surgical knife. Fishtailing and darts are used, and extra skin graft is applied in neck contracture cases.{Figure 3}

The neck wound of either acute burns or after contracture release should be closed with carefully planned skin flap or sheet skin grafts oriented horizontally. Thin skin of neck when used as local expanded or non-expanded flap in limited deformity replaces like with. Skin free flaps are usually bulky and need touch up surgery for aesthetic improvement.Special care is needed to resurface chin to hyoid and hyoid to suprasternal area as separate units with graft or flap junction at cervico-mental crease.[3] Bulky tie-over dressing is used with 6-inch bandage at cervico-mental junction. It helps to give better contouring and decreases shear forces. A betadine-soaked gauze all around tie-over dressing helps to keep graft and skin junction area covered and dry. It decreases maceration, infection, and marginal graft loss. Customized splint wearing is started as soon as the graft heals. We prefer to give pressure garments soon after wound healing for chin and lip burns to improve oral competence and prevent deformities. We follow them up in a dedicated burn and scar management clinic and try to promote inter-patient interactions for their self-motivation and understanding of possible long-term functional and esthetic outcomes. Scar care is taught individually to each patient and demonstration videos are given to them for better understanding and compliance. Social workers in outpatient clinics help by understanding psychological issues of patients. They guide them for the same and make efforts toward social rehabilitation.

Management of burns is a significantly labor-intensive job for the whole team. Ideal neck after treatment of burns and contracture should have well-defined contour, uniform color, texture, cervico-mental angle, and thyroid cartilage prominence superiorly, well-defined suprasternal notch and clavicular border prominence inferiorly, and prominence of both sternocleidomastoids laterally. Thick split skin graft along with optimum postoperative splintage, pressure garments, graft care and physiotherapy give good results in all types of neck contracture deformities [Figure 4], [Figure 5]. Expanded or Non-expanded local skin flaps are ideal for limited deformity whereas skin free flaps are better for moderate to larger area resurfacing in carefully selected cases. Skin flaps provide better cosmesis and work best in cases where risk of recurrence is high.{Figure 4}{Figure 5}

 Conclusion



In spite of providing the best of care, certain issues such as residual deformity, abnormal scarring, and hyper- or hypopigmentation of healed burns are still under research for a definitive solution. There is still a long road ahead in properly managing a burn patient and avoiding contractures and deformities. However, following certain basic principles, we can prevent them in majority of cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1National Health Portal. National Programme for Prevention and Management of Burn Injuries. Ministry of Health and Family Welfare; 2019. Available from: https://www.nhp.gov.in/national-programme-for-prevention-and-management-of-burn-injuries_pg. [Last accessed on 2022 Jan 28].
2Hickerson W, Rives JM. Reconstruction of the burned neck. In: Sood R, Achauer BM, editors. Achauer and Sood's Burn Surgery: Reconstruction and Rehabilitation. Philadelphia: Saunders Elsevier's; 2006. p. 356-63.
3Perera C, Fudem GM. Aesthetic reconstruction of severe postburn neck contractures. Ann Plast Surg 2008;61:559-65.