Post-Burn Hand Contracture / Hand Deformity Correction | Assessment of skin, joints and tendons

Scar contraction across the joint is the most common cause of post-burn stiffness. A stiff hand is assessed by detailed anatomy, mechanics and specific tests that distinguish capsular, intra-articular and extra-articular tightness. Plain X-rays in two views can reveal prior bony injury, malunion, malangulation or secondary osteoarthritis. Dynamic ultrasound can identify tendon rupture, dehiscence, inflammation or soft-tissue tethering, including flexor sheath problems. MRI or CT are currently less useful, although CT may help when altered joint surfaces create a bony block. Deep burns can also cause primary arthro-osseous contractures, which are severe and irreversible. Despite detailed preoperative examination, the exact cause may only be fully determined at surgery.

In burn care, active and passive range of motion are documented with goniometry to track changes over time and guide therapy. Active movement may help tendon gliding and edema control in the acute phase. Passive movement several times daily can be useful when capsular or collateral ligament shortening is present. Therapists compare active and passive measurements to distinguish muscle or tendon limitation from joint or scar restriction. A fixed limitation of active or passive extension, reduced first web opening, or grasp restriction persisting despite at least six months of compression therapy and physiotherapy may indicate contracture needing surgical review. Repeated goniometric records help decide whether stretching, splinting, or surgery is appropriate. This comparison supports individualized rehabilitation and timely surgical consultation.

This is not only skin shrinkage. Scar tightening can be accompanied by stiffness in the thumb adductor and first dorsal interosseous muscles, and sometimes joint stiffness, so thumb movement at its base is restricted. The web space span matters for grip. Treatment depends on severity: slight contracture may be lengthened with local tissue rearrangement, while more distinct contracture may need full-thickness skin grafting or other soft-tissue reconstruction. Full-thickness grafts can help counter shrinkage over a joint and restore flexibility. Release is usually considered after scar equilibrium, often three to six months, because recurrence is less common then. Postoperative splinting, hand therapy and scar care are vital to a successful outcome.

Preoperative assessment includes a complete hand examination focusing on skin quality, previous skin grafts, web spaces and joint range of motion. The first web space is checked through full thumb abduction and opposition, including skin pliability. The entire upper extremity is also examined to determine whether a more proximal contracture release should be prioritized. Hand and wrist X-rays identify bone or joint deformity; long-standing contractures may have dislocated or fused joints. Interdigital webbing may extend to the middle of the proximal phalanx. Scar excision is used for web space contractures and post-burn syndactyly of the second through fourth web spaces. Planning focuses on improving both function and appearance.

Contracture is scar shrinkage after a burn. It can tighten skin, muscle, tendon, ligament and fascia, reducing range of motion. Secondary contractures can shorten muscle-tendon units and neurovascular bundles around a joint, so movement, sensation and circulation may all be affected. Sensation may also decrease from damage to sensory nerves and nerve endings. Severity depends on burn depth, healing time, grafting and joint involvement; rehabilitation often helps, but surgery is considered when function remains limited. Hand burns can affect grip and daily tasks, so assessment should include movement and sensation. Full-thickness skin grafts may help release tightness when appropriate. Splinting, therapy, scar care and follow-up support recovery and comfort.

Severe or chronic soft-tissue contractures can hide bone abnormalities, so imaging is often checked before deciding treatment and planning release. The deformity should be assessed in skin, tendons, joints and bones, because secondary changes in these tissues often limit correction. Release aims to restore pinch, grasp and power grip, not just joint movement. Timing depends on scar maturity, scar equilibrium and individual factors. Flexion contractures can be more challenging than extension contractures, because release may stretch vessels and nerves and risk finger viability. The extent of release matters more than the type of cover provided. Individual assessment, imaging review and careful follow-up remain essential for safe planning and recovery after release and rehabilitation.

Burned skin and scar can tighten over joints and web spaces. Early wound care, positioning, splinting and range-of-motion work can reduce contracture risk and improve movement; in one pilot study, 65% of major joints with contracture improved by at least one severity level during inpatient rehabilitation. Early wound closure and rehabilitation can facilitate restoration of hand function and minimize need for reconstruction. However, if function remains significantly limited despite appropriate splinting, stretching and therapy, surgical release is indicated. Release is usually considered once scar tenderness and redness have settled, often 3–6 months, because waiting 6–12 months for scar maturation can risk permanent loss of motion. Surgical release with graft or flap coverage is the primary treatment modality.

Traditionally, contracture release is best after scars mature, often about a year, when induration subsides and scars pale; some sources describe scar equilibrium around 3–6 months. In children, deformity can progress fast, and delayed release may make musculotendinous shortening harder to correct; joints left dislocated may lose cartilage integrity. Burn scar contractures are common in children despite appropriate initial management, and timely intervention can prevent joint stiffness and potentially irreversible functional deficits. Yet immature scars can recur quickly, so mild contractures may be observed or treated nonoperatively with splinting, therapy, compression or silicone. The decision balances preventing irreversible stiffness against avoiding unnecessary operations during growth.

Post-burn contracture release aims first at complete release and return of function, not just scar removal. If axilla, elbow and hand are all affected on one side, hand surgery may wait until the larger joints are released. For multiple contractures, the order also depends on reconstructive needs, whether procedures can be combined, donor-site availability, expected improvement and your preferences. In hand burns, staged release may address wrist and thumb before fingers. Full-thickness skin grafts are generally preferred over split-thickness grafts for release because they tend to re-contract less, though both can be used. Your surgeon can discuss how these factors apply to your hand.

Function followed by form are the major goals, and planning should improve both functional limitation and aesthetic appearance. Preoperative examination focuses on skin quality, previous skin grafts, web spaces and joint range of motion. The thumb should be examined in full abduction and opposition, including first web space pliability; the entire upper extremity should be checked for proximal contracture; radiographs identify bone or joint deformities. McCauley's classification correlates contracture severity with hand function. Ideally, surgery is considered at least 12 months after burn, after 2 to 3 months of hand therapy with a plateau and a continued functionally limiting contracture.