Contributed by Dr Yeap Choong Lieng
Consultant, Plastic, Cosmetic & Reconstructive Surgery
Contracture deformity is the result of stiffness or constrictions in the connective tissues of the body due to contracted soft tissues or skin over a moving joint. The soft tissues involves are the muscles, tendons, ligaments and the overlying skin. The results are difficulties in moving the joints of the affected parts like the leg, hand, body and other parts involved by the contracture.
The main causes of contractures are severe injuries around the joints, burns injuries around the affected joints or the patient’s inability or refusal to move a painful joint. The results are stiffness of the joint, progressive inability to extend or flex the affected joint. Soft tissues like the lips, eyelids or even the ears can also be deformed by severe accidents or burn. Therefore, it is very important to recognize this problem and start treatment very early.
In severe injuries caused by accidents it is very important as an emergency to repair the damaged structures – fixation of broken bones, repair of the damaged muscle, ligaments and joints and then very importantly the skin. Without a proper skin coverage, all the bones, joints or ligaments are not protected and they will not heal. Unprotected structures are prone to infections and if infected then severe consequences will follow with further destructive damages. In severe injuries with extensive loss of skin, it is necessary to use skin grafts or flaps which are soft tissues with skin to cover the defects. The plastic surgeon is well trained to repair the damaged soft tissues and provide good skin coverage; if the other structures like bone or joints are involved, he can work as a team with other specialists.
After the initial emergency procedures are achieved, rapid wound healing must follow by good wound care and management. Then rehabilitation of the affected joints or body must commence early to ensure that they will attain good or normal range of movements. If these are not achieved in the initial stages then contractures will develop. This will then necessitate surgical corrections of the resultant contractures. The contractures must be carefully and adequately released, tight ligaments freed and the resultant skin defects which are certain after the release of the contractures corrected. This can be achieved by using skin grafts or transfer of flaps to cover these defects. In severe cases it can be a very complicated, multistage, and extensive surgery depending on the severity.
In children with severe burn or accident injuries involving joints or other body areas it is very important to take note of this. The injuries must be treated very early and appropriately to ensure fast healing. After healing, the management of the scars must be of priority as children are prone to keloid formation and this will then restrict joint movements e.g. the neck, finger or leg joints. Even the eyelids, ears or the lips can be severely deformed by the severe scaring caused by any post- burn or severe injuries. It must be stressed that children are still growing – generally girls till the age of 18 years and boys till 21 years old. If there are severe soft tissue or joint contractures, their growth will cause the joints to be permanently deformed and future attempts to correct these deformed joints will be futile or unsuccessful as the joints are already fixed in their deformed position. It will be also difficult to achieve good results to correct the soft tissues contractures around the lip, eyelid, neck or across any joint. The affected mouth or eyelids can be severely deformed. This will require multiple surgeries. Even then, we can only achieve mediocre results. Therefore, in growing children it is mandatory to start the early reconstructive and rehabilitative treatment the moment the wounds have healed together with scar management to prevent keloid forming.
