India, the second most populous country in the world with over a billion people has an estimated annual burn incidence of 6-7 million, based on data from major hospitals when extrapolated to whole of the country, which is the second largest group of injuries after road accidents1. Nearly 10% of these are life threatening and require hospitalization. Children under five years represent 19% of burn admissions, and the upper extremities are affected in about 39% of cases. Although the hands make up less than 5% of total body surface area, hand burns are deemed severe and require referral to specialized burn centers. Accurate assessment of burn depth is crucial to determine the need for surgical interventions like escharotomy or fasciotomy2. Early treatment focuses on elevation, orthotic support in anti-deformity positions, and timely wound coverage to promote motion3-5. In the subacute phase, motion therapy, compression, and scar management are key to minimizing complications. Even with optimal care, functional impairments may develop, particularly involving contractures or webspace deformities. Deep burns often necessitate grafts or substitutes to prevent contractures and support recovery. The dorsal hand is more prone to contractures due to its thin skin and underlying extensor structures. In contrast, the thicker, fibrous palmar skin offers more protection to flexor tendons. Even with early resurfacing, deep hand burns can lead to contractures without proper preventive measures like orthoses, pressure garments, and supervised motion6,7,8. The hand should be positioned in an antideformity orthosis with specific joint angles to preserve function. Elevation and shoulder abduction help reduce edema and prevent proximal contractures. Pressure garments and silicone sheets should be introduced early to minimize scar formation through sustained pressure and tissue hypoxia. Despite these interventions, severe burns can still result in lasting deformities9-11.Deep dermal and full-thickness burns commonly affect the dorsum of the hand due to its thin skin and reflexive exposure during injury. In children, hand burns often result from scalds or friction, with flexion contractures being more prevalent. Graham et al. classified MCP joint extension contractures into three types, aiding surgical planning based on severity and tissue involvement. Severe dorsal burns can lead to claw hand deformity and joint subluxation, often involving both soft tissue and bone. Webspace contractures, including burn syndactylization, can impair function and aesthetics, sometimes requiring radiographic assessment for surgical planning12.Split-thickness skin grafts remain the standard for acute burn wound resurfacing, though graft thickness has not shown a significant impact on range of motion after hand burns. Skin substitutes, like acellular dermal matrices, offer aesthetic advantages by avoiding donor sites but lack proven benefits in preventing contractures and come at a higher cost13. Once contractures develop, nonsurgical options are limited, emphasizing the importance of early prevention. Preventive measures include early motion, pressure therapy, orthoses, scar massage, and sun protection. Additional treatments like steroid injections and laser therapies can aid in improving both functional and cosmetic outcomes of hand burn scars14. AIM: To study the various presentations of post burn contracture and their surgical management in our institute.

This prospective study was conducted in the Department of Plastic Surgery and Reconstructive surgery, Mahatma Gandhi Medical College and Hospital, Jaipur. Patients clinically diagnosed with post-burn scar contracture of the different regions of body were included after informed consent and explanation of treatment options. The study analyzed various presentations, complications, treatment methods, and outcomes. Inclusion criteria included burns older than six months, patients over 10 years of age, including both sex, contractures from thermal or electrical burns, and presence of hypertrophic scars or keloids. Exclusion criteria were acute burns, children under 10, contractures from trauma or inflammation, and chemical burns. Surrounding skin and donor areas were also evaluated to plan reconstruction.

Table 1: Type of burns: Type of burn Number Percentage Scald & Flame burn 72 96% Electric burn 3 4% Flame & scald burns were the predominant cause, accounting for 96% of cases in the study. Electric burns were less common, observed in only 4% of patients. Table 2: sex distribution: Sex Number Percentage Male 31 41% Female 44 59% In this study, females constituted the majority of patients with post-burn contractures, making up 59% of cases. Males accounted for the remaining 41%. Table 3: Distribution according to region of burn: Region of burn Number Percentage Finger/ hand 44 59% Neck 8 12% Popliteal 6 8% Axilla 4 5% Lip 4 5% Elbow 4 5% Foot 4 5% Chest 1 1% The most commonly affected region are the fingers and hands, comprising 59% of burn cases. Other regions included the neck (12%), popliteal area (8%), and axilla, lip, elbow, and foot, each accounting for around 5%. The chest was the least affected region at 1%. Table 4: Distribution according to surgical procedure: Surgical procedure Number Percentage Z plasty 24 32% Z plasty + Split thickness skin grafting / Full thickness skin graft 23 31% Split Thickness Skin Graft 16 21% Full Thickness Skin Graft 6 8% Skeletal Distraction 6 8% Z plasty is the most commonly performed surgical procedure, either alone (32%) or combined with skin grafts (31%). Split-thickness skin grafts (21%), full-thickness grafts (8%), and use of skeletal distraction (8%) were less frequently employed. Table 5: distribution according to use of implants: Use of implants Number Percentage K wire 4 40% Skeletal Distraction 6 60% Implants are used in selected cases, with distractors being the most common, used in 60% of implant-based procedures. K-wires were employed in the remaining 40% of cases. Table 6: use of z plasty in patients: Z -plasty Number Percentage Hand 18 75% Neck 3 13% Axilla 2 8% Popliteal 1 4% Z-plasty is most commonly performed for hand contractures, accounting for 75% of such procedures. The neck (13%), axilla (8%), and popliteal region (4%) were less frequently treated using this technique.

Post-burn contracture is a common issue, particularly among individuals from lower socio-economic backgrounds. Contractures significantly affect quality of life by limiting daily functional activities. In this study, flame & scald burns are the predominant cause of injury, accounting for 96% of the cases. These typically resulted from household or accidental exposure to fire. Electric burns were much less common, observed in only 4% of patients. Our data highlights the overwhelming prevalence of flame & scald related injuries in post-burn contracture cases. The majority of patients in this study were female, comprising 59% of the total cases. Males accounted for the remaining 41%. Our study suggests a slightly higher prevalence of post-burn contractures among females in the study population. In a study by S. Nath15 Five hundred and sixty-two patients with post burn contractures were treated by a plastic surgeon in the Central Hospital of the capital city, Lusaka. There were 37 patients with neck contractures of whom 18 were classified as major, all but two were burned by fire and two-thirds were female. The fingers and hands were the most commonly affected regions, accounting for 59% of the cases, reflecting their high vulnerability during burn incidents. Neck involvement was noted in 12% of patients, often leading to functional and aesthetic challenges. Popliteal contractures made up 8% of the cases, potentially impacting lower limb mobility. The axilla, lip, elbow, and foot each represented 5% of burn sites, with implications for joint movement and facial function. Chest involvement was rare, seen in only 1% of patients. This distribution emphasizes the need for region-specific reconstructive strategies in post-burn care. In our study Z-plasty is the most frequently performed surgical procedure, used in 32% of cases to release contractures and improve function. A combination of Z-plasty with Split-Thickness Skin Grafting (SSG) or Full-Thickness Grafting (FTG) was employed in 31% of patients, indicating a need for additional coverage. SSG alone was used in 21% of cases, while FTG was performed in 8% of patients. Distraction techniques using external devices were applied in 8% of cases, reflecting their role in managing more severe contractures. These findings highlight the diverse surgical approaches tailored to contracture severity and location. In a study by Manu Rajan16 Contracture release with split thickness skin grafting STSG in 25 (55.5%) cases. Contracture release with STSG with flap cover was performed in 7 cases (15.5%), contracture release with K wire insertion with coverage was performed in 8 cases (17.7%) and Z plasty was performed in 5 cases (11%).In a study by Sunil NP17, Forty seven percent of the cases were reconstructed with skin grafting, 30% cases with Z plasties and 23% with flap coverage. Split thickness skin grafts (STSG) and full thickness graft (FTSG) reconstructed cases had good recovery of joint mobility in 43% and 75% of cases respectively. Reconstructive procedures were aesthetically acceptable to the patients in 63%, 75% and 94% of STSG, FTSG and Z plasty cases respectively. Recurrence was seen in 17% of STSG cases. Implants were used in select cases to support surgical correction of post-burn contractures. Distractors were the most commonly used implant, applied in 60% of cases requiring implant support. K-wires were used in 40% of such cases, particularly for joint stabilization and maintaining alignment during healing. A prospective study by Sungur N18 was carried out in 72 patients with flexion contracture of the hand fingers. After the surgical release of the deformity, immobilization of the interphalangeal (IP) and metacarpophalangeal (MCP) joints was carried out with K-wire fixation for 3 weeks. In our study Z-plasty is the most frequently performed surgical procedure for post-burn contractures in the hand, accounting for 75% of the cases. It was also used in 13% of neck contractures and 8% of axillary cases. A smaller number of procedures were done in the popliteal region, comprising 4%. This technique proved especially effective in improving function and aesthetics in joint and high-mobility areas. The versatility of Z-plasty makes it a preferred choice in burn contracture management.

Post-burn contractures remain a significant challenge, especially in lower socio-economic populations, severely impacting quality of life and daily function. Flame & scald burns are the predominant cause, with hands and fingers being the most affected regions. Surgical management varies based on contracture severity and location, with Z-plasty and skin grafting as common interventions. Use of implants like distractors and K-wires aids in complex cases, enhancing outcomes. Early and tailored reconstructive strategies are essential to restore function and aesthetics. Continued focus on prevention and comprehensive care can reduce morbidity from post-burn contractures.

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