Contracture Release and Full-Thickness Skin Graft to Volar Index Finger with K-Wire Insertion
Main Text
Table of Contents
Trauma-related deaths cause many deaths per year, with burns contributing to many of these deaths. The morbidity and mortality of burns have shown a decline since the development of more scrupulous management. The complications stemming from a poorly-healed burn wound can lead to functional deficits and overall aesthetically unfavorable results leading to psychological distress. Due to the inquisitive nature of infants and toddlers, and their nature to learn the world with their hands, their sensitive regions like the hands become likely targets for burns. The rapid growth of infants places extra stress on the surgeon to recreate the normal anatomy of the flawed hand. Management differs depending on the size and depth of the burn wound. Superficial burns can be managed on an outpatient basis with spontaneous healing expected in 2 or 3 days with minimal scarring. Deep burns, particularly in pediatric populations, need considerable attention to avoid secondary contracture that leads to deformity. Many treatment options exist, but in sensitive areas like the hands and face, full-thickness skin grafts are favored due to their superior healing and decreased likelihood of secondary contracture. Advancements in modern medicine have expanded treatment options with nonoperative and operative procedures, along with the utilization of growth factors, such as TGF-B1 that accelerate healing. This article aims to guide the surgeon in managing a pediatric burn wound with an arsenal of treatment options with the goal of achieving full mobility and functionality of the hand.
Post-burn; hand deformity; pediatric; contracture; skin transplantation.
Burn injuries are a major global health issue due to their high morbidity and mortality. The cutaneous scarring caused by superficial and full-thickness burns leads to functional impairment and aesthetically unpleasing results leading to psychological distress. In the first four decades of life, trauma is the leading cause of death and disability, with burn trauma comprising the second most common cause of trauma-related death.1
In cases of superficial hand burns, the return of normal function occurs in 97% of cases, compared to 81% in deep burns.2 Pediatric hand burns pose more risk for functional and aesthetic deterioration due to the rapid growth during childhood and should be treated promptly.3
Contracture of the wound occurs secondary to the interruption of the normal physiologic phases of wound healing: inflammation, proliferation, and remodeling of local tissue.4 For deep burns, in particular, the activation of dermal fibroblasts leads to large quantities of collagen and inflammatory cytokines with less collagenase to break down collagen.4 When fibrocytes migrate from the bone marrow to the injured tissue, they differentiate into fibroblasts and then eventually myofibroblasts, leading to wound contracture.4 When there is a dysregulation between increased type III collagen and decreased type collagen I, this can lead to the formation of hypertrophic contracted scar.4
For our patient, the release of the skin contracture was accomplished via an incision, followed by K-insertion to prevent skin graft loss by inhibiting flexion postoperatively. Our full-thickness skin graft was harvested from the groin region of the patient. An appropriate dressing was added to the skin graft.
A 1-year-old male patient presented to Shriners Hospital for Children following a burn accident 1 year ago. The patient has noticeable scarring near the proximal portion of the index finger with obvious contracture in the flexed position. Prior imaging is unknown at this time. All other patient history is unknown at this time.
The physical exam findings seen in this patient were consistent with a moderate decrease in the range of motion and minimal distortion of the index finger. Noticeable scarring was found along the volar aspect on the index finger with evidence of contracture leading to a persistently flexed finger. No other significant findings were noted.
The natural history of hand burns depends on the extent of the injury and the location. Injury develops due to direct thermal damage or secondary to the intrinsic minus position from edema and vascular insufficiency.2 As discussed earlier, normal hand function is returned in 97% of patients with superficial burns compared to 81% of deep burns. Contraction is the method that deep burns are healed by, and the extent of contracture depends on the amount of skin lost due to the deep burn.2 Palmar burns result in lax dorsal skin, which allows edema to accumulate causing distortion of the anatomical structures in the hand.2 Edema accumulation can lead to compartment syndrome, which needs urgent attention before intrinsic muscle ischemia and distal vascular compromise take place.2 If a superficial burn is noted on a physical exam, it is appropriate to follow the patient on an outpatient basis, however, major burns are an indication for hospital admission.
Regaining full range of motion is the goal when it comes to hand wounds and is optimized with intensive rehabilitation programs starting from day one. Early mobilization once the edema has subsided is an important step as it allows faster recovery.2 Passive stretching of the healing skin is allowed if the burn is left alone for spontaneous healing. On the contrary, active finger movement is encouraged when skin grafting has occurred, preventing the graft from shearing.2
Burn wounds have a multitude of options for treatment ranging from conservative to surgical to biological. With advancements in science and regenerative medicine, treatment options have flourished. The best outcome of a hand burn is when deformities are prevented from developing in the first place. This can be achieved from urgent hand resuscitation during the acute phase, excisional surgery, reconstructive surgery, and physiotherapy. An individual runs the risk of hand deformities when these procedures are not done.2
There are multiple treatment methods available for burn wounds. These include surgical interventions such as skin grafting with K-wire insertion, and non-operative treatments. Non-operative treatments can consist of an antiseptic dressing and aggressive physical therapy to avoid deformities from developing. It’s important to note that these are just some of the methods, and the choice of treatment can depend on various factors such as the nature and extent of the burn wound, a particular wound quality or state, and the patient’s allergy history.3
When deciding what skin graft technique to use, one should consider the pros and cons of full-thickness skin grafts vs. split-thickness skin grafts. Full-thickness skin grafts have superiority over split-thickness skin grafts in terms of their functionality and cosmetic result. Additionally, secondary contraction is minimal in full-thickness skin grafting, and skin color matching is more accurate.3
Occasionally, when a boutonniere or swan neck deformity is evident to happen, early release of the tissue is indicated to prevent attenuation of the extensor apparatus. This comprehensive approach to postoperative care can significantly improve the healing process and the patient’s quality of life.5
In addition to skin grafts, there are other surgical options that can be considered. One such option is skin rearrangement, also known as Z-plasty. Z-plasty is a surgical procedure that involves making a Z-shaped incision along the line of the greatest tension of a scar. The upper and lower triangular flaps are then ‘switched’ to the opposite positions. This technique is used to elongate the scar, thus reducing tension and improving both the functional and cosmetic appearance of the scars.11
Another option is the use of more complex skin donor flaps. These flaps, which bring their own blood supply from the flap donor site, can be used depending on the location of the scar and a patient’s personal goals. These procedures can be particularly beneficial for large grafts and flaps, and may require an inpatient stay.12
Postoperative emollients such as antibiotic ointments or creams are often used to keep the wound moist, prevent or treat infections, and aid in the healing process. These emollients can also help to reduce inflammation and accelerate the healing process.13
Massage is another important postoperative measure. It can help to stimulate the lymphatic system, aiding in the drainage of excess fluid, reducing inflammation, and accelerating the healing process. Skin rolling can help release the scar’s attachment to deeper skin layers, while indirect myofascial release can help ease the nervous system through easing the scar’s pressure. Findings indicate that scar massage could be beneficial in reducing scar height, vascularity, pliability, pain, pruritus, and depression associated with hypertrophic burn scars.14
Splintage plays a crucial role in burn wound management. There are three types of splints usually used with burn patients: static, static progressive, and dynamic splints. Static or primary splints are used in the acute phase for skin graft protection after surgery or anti-contracture positioning. These splints are applied to adjacent intact skin. In addition, exercises are also vital for maintaining and improving the range of motion.15
The rationale behind the treatment was that by releasing the tension on the volar surface of the index finger, we would be able to fully extend the finger, allowing for a full range of motion. A defect will be created on the volar surface that will be embedded with a full-thickness skin graft. A K-wire will be implanted into the finger for stabilization in the extended position to prevent finger flexion that may lead to loss of the skin graft.
A 1-year-old male infant presents with a volarly-flexed index finger around one year after suffering a burn to his index finger. The goal for the procedure was to release the contracture, insert a K-wire for stabilization, and place a full-thickness skin graft. The hand and distal forearm were exsanguinated to decrease bleeding during the procedure. An incision was made to the proximal index finger. Hooks and a 15 blade were used to retract additional skin. Careful manipulation of the skin and fascia was done in order to avoid damage to nearby neurovascular structures. Through the meticulous spreading of fascia using an Adson with teeth, the optimal release of the contracture was achieved. The exposed fascia was measured with a ruler to determine how much graft would be needed for the graft. The donor site was the groin crease. A scalpel and a snap were used to harvest the graft from the groin crease, followed by the removal of fat from the graft. Local anesthetic was applied to the donor site, followed by closure using 3-0 Monocryl for the dermal layer, and 4-0 for the subcutaneous layer. Dermabond was also applied. Before the K-wire was inserted, the index finger was cauterized to limit bleeding. For better control and stabilization of the wire, the performing surgeon choked up on the K-wire into the drill. The K-wire was inserted down the shaft of the index finger ending at the metacarpophalangeal joint, which inhibits any mobility of the finger. Since the release was near the metacarpal head, the K-wire was inserted in a way that would only allow the finger to move as one piece, which was confirmed after placement. Confirmation of adequate blood flow to the finger before and after K-wire placement was performed. Next, a 2/8 Jurgan ball was inserted at the tip of the K-wire to protect the tip of the finger. Next, the skin graft was applied using 4-0 chromic absorbable sutures. A nerve block to the index finger was administered to ease any pain when the patient wakes up. The decision to make the incision site above the old scar was made because the skin from the crease had been displaced distally, allowing him to give the patient’s hand more glabrous palm skin, which is important in a growing toddler. The surgeon covered the wound with Xeroform dressing, sterile gauze, and a plastic splint that held everything in place.
Burn patients may face psychological and functional deficits secondary to skin contracture months or even years after the inciting event. Considering burn injuries rank third among injury-related deaths in children aged 1 to 9 years of age, special care is imperative.6 The pediatric populations have certain features that merit extra attention. Distinguishing features of children include the physiology of fluid and electrolyte handling, differences in energy requirement, and various body proportions, warranting a different treatment perspective than adults. It is proposed that if this special care is taken during the initial management, these children can better integrate into society.6
Children, compared to adults, have a larger body surface area of the head and neck, relative to their overall body size. This difference should be considered when calculating the extent of the burn injury. Children have about three times the body surface area to body mass ratio of adults, therefore fluid losses are proportionally higher in children. This rapid fluid loss can lead to hypothermia, which should be avoided. It is known that children younger than two years of age have thin layers of skin and insulating subcutaneous tissue, predisposing them to hypothermia.6 To further add to the injury, temperature regulation in very young children is partially based on non-shivering thermogenesis, which consequently increases the metabolic rate, oxygen consumption, and lactate production even further.6
An additional consideration that needs to be made is the necessity of pediatric patient admission. Some indications for hospitalization include: partial thickness greater than 10% of body surface area, full-thickness burns greater than 2% of total body surface area, and burns involving the face, hands, genitalia, perineum, or major joints.6
When fluid resuscitation is needed, special attention needs to be given to infants due to the higher metabolic rate, which is responsible for the increased amount of renal water loss. The Parkland Formula calculates how much fluid should be given to the burn patient over a certain period of time. For use in the pediatric population, Shriners Burn Institute made a modified version of the formula.6
Absolute contraindications for skin grafting include incomplete removal of cancer from the site, active infection, and uncontrolled bleeding.7 Relative contraindications include smoking, anticoagulant medications, bleeding disorders, chronic corticosteroid usage, and malnutrition.7
Additional considerations for split-thickness grafts include avoidance of near-free margins due to the increased risk of secondary contracture. In respect to full-thickness grafts, they should not be used on avascular sites greater than 1 cm.7 In addition, special care must be taken not to injure the flexor tendons and neurovascular bundles on the radial and ulnar side of the index finger.
Trauma causes many deaths around the world with burns wounds being responsible for most of these cases.1 Our patient experienced a burn wound to the index finger approximately 1 year prior to seeking treatment and had noticeable hypertrophic scarring that led to contraction of the index finger in the flexed position. This finding was an indication for operative management to release the contracture and regain the full range of motion and functionality of the injured finger. K-wire insertion and a full-thickness graft were used to treat the patient.
Burn wounds lead to the disruption of the normal skin barrier that needs to be replaced, either with spontaneous healing or through the use of autologous donor sites.8 Skin grafts have been used since the 19th century and are recognized as the mainstay treatment for treating lost skin tissue.6 Split-thickness skin grafts have been the gold standard for such procedures, although there are many downsides to this technique such as the creation of a large wound, which contributes to increased pain, risk of infection, and scarring.8 Additionally, split-thickness grafts lack the necessary elements such as dermal fibroblasts, hair follicles, and sweat glands for proper wound healing.8 These factors lead to scar formation, skin contracture, and desiccation of the wound.
Comparatively, full-thickness skin grafts show less skin contracture and less scarring because they include the components for optimal wound healing. However, a disadvantage to full-thickness skin grafts is the requirement for rapid blood supply secondary to higher metabolic demand.8 The burn was in a sensitive aesthetic region; therefore, full-thickness skin grafting was preferred for this patient, as a secondary contraction would lead to significant functional deficits from a clinical perspective.
Aside from conventional skin grafting techniques, modern medicine for burn wounds has shown significant progress in the last 10 years. With advancements in the field of regenerative medicine, biologic agents have shown promising results. The immune system plays a major role in the healing process of burn wounds, thus providing a target for treatment. Immune-based therapies include macrophage-activating-lipopeptide-2 (MALP-2) and platelet-rich plasma gels to resolve chronic burn wounds.9 Varying levels of success in clinical trials have been shown with transforming growth factor-B1 (TGF-B1), interleukin-10 (IL-10), mannose-6-phosphate (M6P), and nefopam for scar prevention.9
According to Larouche et al.9, TGF-B1 has shown to decrease scar size in both phase I and II clinical trials, although full regeneration was never seen. Furthermore, TGF-B1 therapy in the early stages of wound repair accelerates wound healing consisting of self-limited recruitment of immune cells, which is followed by cellular proliferation and re-epithelialization. However, once the remodeling phase has taken place, TGF-B1 therapy can lead to increased scar formation.
The development of a newer and cost-effective treatment is possible. Genetically modified porcine skin [alpha-1, 3- galactosyltransferase knockout (GalT-KO)] can become an easily accessible xenograft in the near future. This advancement has been shown to have a similar tolerance to fresh or cryopreserved allografts. Apligraft is a type of “complete” graph that contains epidermal and dermal elements and has shown to improve cosmetic and functional outcomes compared to an autograft.10
Although this paper mentions the ongoing research for new options for burn treatment, there are a number of treatment options in clinical trial phases. With new methods that are being discovered every year, the decrease in complications and psychological distress will reduce the morbidity and mortality of burn injuries, overall improving the quality of life of patients.
K-wire, K-wire inserter, cutter, bender, splint.
Nothing to disclose.
The parents of the patient referred to in this video have given their informed consent for surgery to be filmed and were aware that information and images will be published online.
Citations
- Goel A, Shrivastava P. Post-burn scars and scar contractures. Indian J Plast Surg. 2010;43(Suppl):S63-S71. doi:10.4103/0970-0358.70724.
- Bhattacharya S. Avoiding unfavorable results in postburn contracture hand. Indian J Plast Surg. 2013;46(2):434-444. doi:10.4103/0970-0358.118625.
- Park YS, Lee JW, Huh GY, et al. Algorithm for primary full-thickness skin grafting in pediatric hand burns. Arch Plast Surg. 2012;39(5):483-488. doi:10.5999/aps.2012.39.5.483.
- Finnerty CC, Jeschke MG, Branski LK, Barret JP, Dziewulski P, Herndon DN. Hypertrophic scarring: the greatest unmet challenge after burn injury. Lancet. 2016;388(10052):1427-1436. doi:10.1016/S0140-6736(16)31406-4.
- Goel A, Shrivastava P. Post-burn scars and scar contractures. Indian J Plast Surg. 2010;43(Suppl):S63-S71. doi:10.4103/0970-0358.70724.
- Sharma RK, Parashar A. Special considerations in paediatric burn patients. Indian J Plast Surg. 2010;43(Suppl):S43-S50. doi:10.4103/0970-0358.70719.
- Prohaska J, Cook C. Skin Grafting. [Updated 2020 Sep 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532874/.
- Tam J, Wang Y, Vuong LN, Fisher JM, Farinelli WA, Anderson RR. Reconstitution of full-thickness skin by microcolumn grafting. J Tissue Eng Regen Med. 2017;11(10):2796-2805. doi:10.1002/term.2174.
- Larouche J, Sheoran S, Maruyama K, Martino MM. Immune regulation of skin wound healing: mechanisms and novel therapeutic targets. Adv Wound Care (New Rochelle). 2018;7(7):209-231. doi:10.1089/wound.2017.0761.
- Stone Ii R, Natesan S, Kowalczewski CJ, et al. Advancements in regenerative strategies through the continuum of burn care. Front Pharmacol. 2018;9:672. Published 2018 Jul 9. doi:10.3389/fphar.2018.00672.
- Gümüş N. Repairing post burn scar contractures with a rare form of Z-plasty. Ulusal travma ve acil cerrahi dergisi = Turkish journal of trauma & emergency surgery: TJTES. 2015;21(3):187–192. doi:10.5505/tjtes.2015.97404.
- Ono S, Sebastin SJ, Ohi H, Chung KC. Microsurgical flaps in repair and reconstruction of the hand. Hand clinics. 2017;33(3):425–441. doi:10.1016/j.hcl.2017.04.001.
- Wasiak J, Cleland H, Campbell F, Spinks A. Dressings for superficial and partial thickness burns. Cochrane Database Syst Rev. 2013 Mar 28;2013(3):CD002106. doi:10.1002/14651858.CD002106.pub4.
- Ault P, Plaza A, Paratz J. Scar massage for hypertrophic burns scarring-a systematic review. Burns: J Internat Soc Burn Inj. 2018;44(1):24–38. doi:10.1016/j.burns.2017.05.006.
- Porter C, Hardee JP, Herndon DN, Suman OE. The role of exercise in the rehabilitation of patients with severe burns. Ex Sport Sci Rev. 2015;43(1):34–40. doi:10.1249/JES.0000000000000029.
Cite this article
Boyle RP, Poster J, Friedstat J. Contracture release and full-thickness skin graft to volar index finger with k-wire insertion. J Med Insight. 2024;2024(287). doi:10.24296/jomi/287.
Procedure Outline
Table of Contents
- Mark Donor Site
- Inject Epinephrine
- Harvest Graft
- Trim Fat from Graft
- Close Donor Site
Transcription
CHAPTER 1
So today's case involves a kid who had a burnabout a year or so ago, and as oftentimes happens,like we try to get them to range and move their fingers,but sometimes the forces of scarringcause the finger to flex volarly, as he has. And so what he's got is kind of a-a flexed- sort of index finger that he can't fully straighten.And what we're gonna do is release the tension on the volar surface of thefinger, so that it can be fully straightened.We'll create a defect on the volar surface of the skin and then we'll put a skingraft in that.Because we're going to be releasing it on his finger, and he is not going to keephis finger straight for us,we'll put a metal K-wire down his finger to hold it in position.This will prevent the finger from moving and losing the skin graft to shear.It will also help keep the skin and everything fully straightenedso when we sew everything in,we know it will be in a good position functionally for him. Because he's soyoung, there's certainly a chance that this is going to recur,and since it's a small defect,I think the best option for him would be a small full-thickness graft, where wecan take a pinch of skin from his groin. It's not going to be a big defect,if it were a larger defect, then we would use a split-thickness graft.In terms of this operation,I'd say the- I was going to break it down into 3 steps- maybe the-3 to 4 steps at most. One is release the scar tissue,taking care not to injure the,flexor tendons, and also be mindful of the neurovascular bundles on the radialand ulnar sides of the index finger. Once the finger is fully straightened,then placing the K-wire in place, so that it is stabilized, and that we know thesize of the defect. And the third is sewing the skin graft in.And then the fourth, if it's big enough, is to put a bolster or some type ofdressing on, and that may be a dressing that as sewn in place, wrapped in place,and/or reinforced with some thermoplast,which is a splinting material to help hold his finger outso that he can't- try tominimize the chance that he can move it while everything is healing.
CHAPTER 2
So you can see like his palmar skin has gotten pulleddorsally, so what we're going to do-do you have a marking pen?What we're going to do is try to release it so that it will goback to where it used to be. So, the scar is sort of tightest along here,so we'll probably...Is that the scar from a prior release or is that from something else?It may be just from how he's healed, because-you can see how it's all pulling- once we do that,then this palmar skin will go back that way, this will go this way,there'll be a space, and we'll put a little skin graft in.So, what we'll do, rather than put like a full tourniquet on,what you can do is do the same thing, so what I'm going to do isI'll get this started wrapping. I may have to wrap a little higher on the forearm.I'll do this for his little fingers.That looks a little more blanched.That's so you can tell it actually is sort of working, it's not perfect, but it's-it's going to slow down the bleeding. Can I see a 15 blade and a epi soak?
CHAPTER 3
All right.So again, I'm holding tension on it here.It'll be similar to what we've done before where it was justvery light pressure.Incision.Okay, yes, if you just set that there, i'll probably use it in just a little bit.We'll take the small double hooks.So you can see the start of that release.And now we're going to do the same thing as before.One right there.1515 would be great.Because everything's all distorted with the scarring,I'm very gentle about how much I'm releasing because I worry about theneurovascular bundles underneath.Because depending on where we're at,sometimes they can get distorted in their location.And so, the last thing you want to do is think that they're not there.And find out in fact they are there, and then you give yourself a real problem.So what you'll see now is like, his finger is pretty straight, and you canprobably- we can give the K-wires backbecause now most of it I can do just by my-you know, now the finger's in a much safer position.So- let's just released this a little bit more.This one you don't get to create as much of a trough, because the finger is sotiny, but you can see now, like the finger is straight.And we can probably get a little bit more of a release over here.So what I'll have you do is I want you to hold the finger like this for me.Put your index finger underneath.I'll take Adson with teeth.So again, I try to grab inside, underneath.One thing that's different with hand and hand surgery is a lot of spreading,very little removing of tissue.Because there's so many important structures in the finger-can I borrow this from you for one sec?Also, the tip is always curved up, so, I can't injureimportant structures. If the tip is curved down, then I can cause problems.And so, what you can see-like, we're sort of creating a little bit of a trough here,but it's not the same as before. Exactly.And even if I ever do grab on the skin like I do here,it's very gentle and it's very minimal.Sometimes you can just do it all with-spreading alone, but...There we go.So now you can see-the finger is really, really straight. If we go a little bit deeper,you'll start to see the flexor tendon here,and so, that's what I'm trying to avoid, and by leaving this tissue over it,it should protect it,so we don't have to worry about the problems of tendon exposure.But you can see, like significant laxity,now his crease is back where it's supposed to be. And there's extra skin too.The same thing over here.How long do the K-wires need to stay in once they're placed?Usually a couple of weeks- can I see a ruler please?So, now we measure the size of our skin graft, so we need about-a little more than a centimeter by-a little less than 2. Marker?
CHAPTER 4
So, if we did like a little- so that's 2.5.So we said we need a little more than...Did you say we place it right in the crease? Mm Hmm.So if we need like something like...Like that should be plenty. So then what we'll do is we just taper.That'll give us plenty of skin, might even be able to make it smaller,and do something like this.Because this skin is going to stretch a little.Okay.
This will just help us with some hemostasis.No, full.We need one more Kerlix.Heavy scissors.And then you can peek- it bleeds,finger's pink- that's what you want to make sure of.And then we can just- that there.
So,a lot of this is also feel.Do you have a snap?What we can then do is- substitute this here.Perfect.And once you've sort of released these edges a bit...I'm really gentle with this when I do it over my finger,I'd rather have there be a little fat like there is here.Are full-thicknesses always harvested in this fashion, or can you do it with-like a thicker setting on the dermatome?Some people have tried it with a thicker setting on the dermatome,I don't think that works as- like,you're basically taking a really thick split most of the time,But you can do it.
Some curved- another snap.So what you can see here is we got a good amount of the fat off, not all of it,And then I put another snap on the other side, and it acts as a weight,so it kind of sets it over my finger nicely.Now what we do is trim off the fat.The one nice thing about little grafts is there's not much fat.Do you have another snap?Mm hmm, yes, these are good.And what you should see is a mostly white surfacebecause that's all that what we're looking at right now is the dermis.Got rid of almost allof the fat. Sometimes it's really hard to get it all.His came off nice and easy, which is...All right, here's the skin. We can just wrap that in a- some- in a moist-let's see how this looks.
We'll need the 3-0 Monochryl in a sec.And then, can I take the local?Okay.So we'll put some in here.Do we close this primarily?Do you have more?Then we'll close this primarily, exactly.Do you do 3-0 interrupted, and then?Yes, 3-0 dermal, and then a 4-0 subq. I'll take the 3-0 Monocryl, please.You can cut those right on the knot, perfect.Sometimes you get a little dog ear, we'll fix that.You can try to hide it in the groin crease as best you can.No, Dermabond, and that's it.We'll fix this.That looks better, we'll fit that with the-with the Monocryl because- you saw how it was pulling in?Sometimes you can get it with a stitch,but when it's dimpling like that, and he grows, like he's gonna want hisskin crease to be able to move with him. Yep. Plus the 4-0 will have a-you can put them in deep, and get it to fix it sometimes for you, so...Let's see, like- that should heal in a way where he's really not going to notice it too much.And the morbidity is much lower from this, like-even if we tried to take a tiny split-thickness skin graft, like...The machine, even at its smallest setting, would harvest way more skin than what we need.And so...If we needed that much skin it'd be a different story.Then what we'll do is-dunk this so the knot goes deep.Since the Dermabond takes a little while to dry, and you almost always want todo it at the very end, when you want to just be done. I just put it on now so it'll-by the time we're done sewing, and K-wiring, and doing all our stuff...This is a really good dressing for kids,because you put it under their diaper, and they can get it wet, and nothing happensbecause the Dermabond protects it.Let me just make sure his...If I put extra, I just want to make sure that it sits in the skin crease open.Because if we glue him with his skin crease closed, he won't be so happywhen he tries to move, and he won't be able to tell his mom and dad that.So what I'll have you do with your left hand is just hold his skin open likethis for a little bit- oh sorry, with your right hand- other left.These are a little harder to make those little darts because it's just so tiny.Let's see, I think this will work.I don't mind bleeding from the skin edges too much, it's actually-a good sign.All right, K-wire.
CHAPTER 5
Can you go up on the gas? Can you please- yeah.Keep going.A little more.All right, well, it should work.So now...I choke up on the K-wire initially, so that I have good control over it.And it's a lot of visualization because-it goes in right under the nail, that's where the...And then I aim straight down the shaft of the finger.And once I kind of get it started...Now we're going to try to line this up so it's in a good plane this way,running along the axis, and then also in a good position the other way.Sometimes you have to stand to do this.Move these things out.So again, a good position there, and then always check both...And you'll feel it as it goes throughbone, it will slow down.Now let's see where we're at.And then push to show- that's right.It was that a little too shallow there, could see it coming towards the finger, so then...So, I'll angle a little bit more volar this time.That's better.So now you'll see his finger doesn't really move, but it's still, again,it's a little- it keeps moving- you can see how it's lined up.It's still coming a little bit dorsal there, so-I gotta change my angle a little bit more.He's withdrawing just a little bit.The dry Raytech.It's in a good plane laterally, sometimes there's just one position, just-works better.Scissors.A little further, and then hopefully it should immobilize at the MCP joint.That's MCP. That should make it.There we go. Yeah.Now, it can... Almost there.That'll hold him, yeah, see now how the whole thing- it doesn't move, it's-he can't bend that finger, that's the key.Sometimes they're a little easier to place than others.Do you drill it through all the bones of the finger? Do you drill it into the bottom part?Yes, you get it right in the distal phalanx at the- right under the nail bed.And then you try to run it straight down the shaft, and you kind-you can do it with a C-arm or you can do it with visualization,just visualizing like where your fingers are and then imagining the trajectoryof the wire passing through everything.But you don't drill it into like the hand or anything?You go to- for him, in order to stop him from moving his index finger,I'll go through into his metacarpal, so he won't be able to bend anything.You could stop it probably right here,but because his release is close to his metacarpal head,I'll take it further so that the whole thing moves as one piece.He needs anesthesia for a K-wire removal, right?You at least would want to mask him probably, I think.Yeah, we have the Jurgan's balls? Yes. That's at 3/5. What you get?The 2/8? Do you have 2/8's? Yeah. Yep, we do.Because otherwise I can cut it and bend it back.Yeah, we have it. Okay.So then, let's do- we'll do a Jurgan's ball so you can see.So I'll have you just hold that there. Wire cutters. We'll need a 2/8Jurgan's ball too.If we were doing more complicated stuff, you'd use a C-arm to look,but you can feel, like clinically, you can see this finger does not bend.It's all one, it all moves as one piece, so I know that I got in the bones.If it's- K-wires are good if you need to have it be like really perfect,but you can also tell clinically.And because this is a short-term, you don't need-it doesn't need to be as perfectly precise,it just has to stop him from moving, that's its function.It protects the tip. so that- all right.Can we see our skin graft?
CHAPTER 6
Are you using a 4-0 Chromic for that? Yep.Unfurl it.Let's start here, we'll get the corner tacked in, and then...I don't think we're going to be able to sew a dressing in on him,so we'll take some Xeroform and we'll fold it, to compress it, and then we'll wrapit with one of those little baby clings. Okay.The smallest ones you got, the little tiny like,the- if they're smaller than a one, I would do the smallest,the little, little baby ones is what we'll...Now it's just the same thing.An important thing to always make sure- when you release these finger, issometimes the neurovascular bundles can get- like can spasm,or sometimes if they've been really badly scarred, you might lose some of that blood supply.So when you straighten the finger out before you put the K-wire in, you want tomake sure there's good blood supply, which we did,but then also even when you put your K-wire in,like if for some reason you accidentally got into one of the neurovascularbundles, you would want to make sure that the finger has good-still has good perfusion,which in this case you can see it's nice and pink and healthy looking.And then you do the same thing when we put the-when we go to put the dressing on. Because if you make it too tight,baby is not going to be able to tell you that this is too tight, it hurts.They'll cry, but how do you distinguish one type of crying from another?And the last thing you want to have is the finger loses blood supply from doinga good operation, but putting a bad dressing on.Now let's see what- so there's extra.All right.So now we're just going to trim the extra.So, one trick if you're not a hundred percent sure of where to cut to,is you can just make a vertical slit.So what you can do is you make your vertical cut down,until you're at basically thelevel where you want it to be, or where the sort of, the groove of that is,so probably a little bit more.And then when that lines up, flushed with the edge, then you know that-you can sew it in place. This is a technique plastic surgeons use a lot.Where it works really,really well is like face lifts, when you're trimming off the extra skin there, but-it's good when you're like-you want to make sure that you don't cut off too much extra skin.And all you're doing is another sort of principle of like makingsomething progressively smaller and simpler.So you bisect it and split it into 2 smaller little wounds.And now you can sort of see where those two edges of extra skin are even moreclearly because now that piece is tacked in. So then...You come back, you can see there's a suture here, suture here,so all you have to do is just cut between.Oh, perfect.And then we can do the same thing here.That'll fit perfectly.We may have to trim that one out.Sometimes you tack them in, if it's not quite perfect,you may have to adjust it a little bit, but we'll see here in a sec.And borrow these scissors, so...So, another thing is never be so happy with your stitch that you're not willingto take it out and redo it if it doesn't look right.Let me borrow this for a sec.You want rehab to come in too? Yes.And then what we can do is block his finger too.Sometimes you can get the knot to sit on the inside here, like this.We'll take a sloppy wet and a dry.Yep.
CHAPTER 7
And then we'll give him a little block here, because we like him.And then a little bit more right here.That should make him happy.Well, I went above it into the scar because the skin from the crease had been displaceddistally, soI tried to look where the skin wanted to go back to and then I made the-the contracture release incision there, so that he would have more glabrous palm skin.And then leave a rim of scar like you've seen.And for these little ones, I find it's very difficult to-to make a- like to sew a dressing on, like- a tie-over bolster just doesn'treally make sense to me, so, I just roll the Xeroform up.Small, full, big ones, split,I mean, that finger is so tiny-honestly, like the chance of him needing another release is high, but-like that's your donor site versus trying to take a shave of skin,which will be much harder.So, that's why.This is one of those times where I hear what Donelan says, but I-I'm not sure I would do a- a split-thickness I think will be a-you'd be more morbid from the donor site.All right, now, this is the baby..., see I told you it's like a-it's like a really big Mentos. All right,so now, if you hold the hand up here.All right.And then once you get it here,you can slide your hand- right hand down to the forearm.Come down around the wrist, because there's no way he's going to just leave that thing alone.So, I want you to just hold his fingers out here, yeah, perfect.Well I think we're probably good at this point.This will be for their splint.They can protect it with the splint.And if they want to wrap over it, I'm fine with that.
CHAPTER 8
So, you know, overall the operation I think went really well.We were able to get the finger fully out in extension,without any tension, and get a small little graft in there from his groin,which should allow him to heal and have good- full mobility of his finger.The K-wire was a little harder to place,but what you do is, sometimes when you have difficulties with it,you look to see what you're doing wrong and then you keep adjusting until youget it in the right position.And by the end, we had at where he couldn't move his finger at all,which was exactly the way we wanted it to be.In terms of recovery, again,in similar principle of like if you leave the dressing on for a little bit longer,the graft will be more healedand certainly with full-thickness grafts,because they have more-they're are all of the epidermis and dermis as opposed to a split where you onlyhave a portion. It takes longer for those grafts to really heal in,so leaving the dressing on here for a couple of weeks is nice because if thereis any epidermolysis and the epidermis on the-on the full-thickness graft sloughs off,it's all going to happen under the dressing, and then most likely be healed by thetime you take it off in 2 weeks. And you know, for- for this kid,could you try to do it at the bedside, and have him come in quickly and pull theK-wire? Yes.It's much easier when he's not moving around, and if there's any stitches youhave to trim out, you can.But all the stitches were absorbable on purpose, so that-if for whatever reason the dressing came undone, or he couldn't have the stitchescome out, there would be little harm to him.The biggest complication you watch for with this operation is that the scarringcan displace the neurovascular bundles.Usually they get displaced volarly and centralize, so as you're releasing it,the biggest thing to watch out for is that you don't injure those neurovascularbundles as you're performing the contractual release.His was not a very deepscar, so we didn't have to get past much to the subq fat,which then protects both the neurovascular bundle to some degree and also the flexors.If you do find yourself looking over them and you need to see them to do therelease, then you want to make sure you fully visualize them. In his case,we didn't get to a depth or a width in those areas where it was necessary to golooking for them.When you release the finger,you also want to then make sure that it's reperfused, and he had good perfusionto the tip of his finger, both after the releaseand then also with the K-wire placement.The last thing you always want to watch out for is as you're wrapping the dressing on,like you don't want to make the finger dressing too tight, and you make sure thatyou test that by looking at the cap refill of the- either the nail bed or thefinger pad, and in this case it looked good. So you know,I would expect him to do well.Really important thingis rehab and their splint that they put on him,so they put on a plastic splint that will protect over not only the tip of thewire that's got a rubber stopper on it,but also around all his fingers, so that he doesn't chew on it and do things thatkids that are, you know, 2 years old roughly will do.And the splinting and the K-wire,all these things are designed to basically prevent the graft from moving,so that it heals well. Those are the really- the important things,and the splinting in kids, in particular in burns, is really,really critical to getting good results.If you don't have a tourniquet,you can always use an Esmark, like we did there, and you can do it on-if you're doing just a finger,whether it's a release and a graft on the tip of the finger, if you don't want to-if you don't have it an Esmark, you can get a glove, cut a hole in the glove,and then roll it into almost like a ring,and it creates a band that creates a tourniquet on the finger, so that you canthen do whatever work you need to on the finger, and make sure you cut the band.So those are ways to help minimize bleeding,so you're able to work on small fingers easily and see what you're doing.