Post-Burn Hand Contracture / Hand Deformity Correction | Release and tissue replacement

Z-plasty reorients tension and lengthens a smaller scar contracture, and scar bands in joint lines are especially well managed with it. Release is usually considered only after scar equilibrium, often 3–6 months, and ideally after about 12 months for full maturation. Hand therapy must first plateau while a functionally limiting contracture remains. The release incision often extends into adjacent unscarred skin, and larger defects may need grafts or flaps. Multiple operations may be needed, and children may need more procedures during growth. Attention is paid primarily to improving functional limitation, while appearance is also considered. Scar bands that remain tight beyond growth spurts are candidates for release.

After a burn, scar shrinkage over a joint can tighten skin and limit movement. A full-thickness graft is thicker and less likely to wrinkle or contract, and previous studies suggest it can improve functional outcome. For the palm, full-thickness grafts are preferable because split-thickness grafts tend to wrinkle and restrict motion. Skin grafts for contracture release are simple and reliable, but they can recontract; full-thickness grafts are recommended whenever possible. The dorsum needs considerable skin, so thick split-thickness grafts may be an alternative when donor skin is limited. Children may need more procedures during growth spurts, and grafts can show increased pigmentation that most patients tolerate.

Contracture release aims to restore movement, but severe scars may require deeper release, tendon lengthening or joint work. If tendons, joints, flexors or nerves become exposed, a skin graft may not reliably protect them; flap coverage is then preferred or mandatory. Even when grafting is planned, the surgeon must be prepared for exposure. Flap planning may be needed before surgery, especially in severe contractures. The wound after release can be larger than expected, so procedures may be staged. Full-thickness grafts can help counter shrinkage over joints, while split-thickness grafts may recontract more. Postoperative splinting, hand therapy and scar care are vital.

The primary goal is complete release and restored function, with return of function as the prime aim. Excision of surrounding scar is secondary and should not compromise the patient. In very severe contractures, ancillary procedures such as tendon lengthening or recreating the extensor hood may be needed in severe cases, and the surgeon should be prepared. Joint release can be difficult when tendons and capsular tissue are severely involved. If tendon or bone becomes exposed, flap cover may become mandatory. The amount of skin coverage needed is frequently underestimated. Further tendon grafts or transfers may be staged later. Postoperative splinting, hand therapy and scar care are vital to a successful outcome. Recurrent contractures may require reoperation.

Safety depends on protecting the index radial neurovascular bundle beneath the flap during dissection. The thumb is held abducted with Kirschner wires or an external fixator, and the released area may be covered in stages with a proximally based triangular flap and temporary split-thickness skin coverage. Full-thickness skin grafts are preferred to split-thickness grafts because they tend to recontract less. Complete release is the primary goal; scar excision is secondary and only if it will not compromise blood supply. The surgeon must be ready if tendon or bone is exposed, because flap cover then becomes mandatory. Release is usually considered after scar equilibrium, often 3 to 6 months, and children may need further procedures during growth.

Burn contractures involve skin loss plus secondary changes in tendons, joints, vessels and nerves; these often limit correction . Complete release matters more than the type of cover, but adjacent releases may be separated because blood loss can be substantial and the wound size after release should not be underestimated . Proximal contractures are usually released first; after resurfaced skin settles and full movement returns, the next distal joint is addressed . The cause also matters: flame burns may need skin release, while trauma or congenital contracture may need tendon management too . Planning also considers donor-site availability, scope of improvement and patient goals . Staging can protect circulation and allow healing .

Selection considers skin thickness relative to age and healing, colour matching, durability against wear, functional needs, hair bearing, moisture and ease of concealment. Donor-site availability can be limited after extensive burns, so material is allocated carefully. Thicker grafts contract less than thinner ones, supporting thicker grafts for the hand. Full-thickness grafts are recommended over split-thickness when possible because split-thickness grafts are linked to more releases and a shorter interval to first release. Common donor sites include upper thighs and buttocks; lower abdomen or groin full-thickness grafts often allow primary closure, while retroauricular, cervicopectoral and upper inner arm full-thickness grafts are best reserved for head and neck.

Burn deformities arise from skin loss and secondary changes in muscles, tendons, joints, blood vessels and nerves, which often limit correction. Evaluate skin, tendons, bone, joints, vessels and nerves when planning. The extent of contracture release matters more than the type of cover; merely excising a graft or scar and replacing it with a flap will not restore function. Complete release with suitable soft-tissue cover is needed, and split-thickness grafts tend to recontract more than full-thickness grafts. The power of scar to cause recurrence is often underestimated, and inadequate release is a common cause. Good splinting and therapy help maintain surgical gains, but they rarely increase range beyond what was obtained on the table.

Burn deformity starts with skin loss, but long-standing bending changes deeper structures. Muscles, tendons, nerves and vessels may shorten and act like bowstrings, so forcing full straightening can risk circulation or nerve stretch. Flexion contractures are especially challenging because release may stretch vessels and nerves. Scar keeps contracting, and recurrence is common if release is incomplete. Surgery aims for the maximum safe release; correction achieved on the table is usually the maximum gained, and splinting or therapy mainly maintain it. In severe cases present for decades, complete correction may not be possible. When bones or joints are also affected, orthopaedic consultation may be needed.