1 years child with regio manus

sinistra contracture et causa

combustio
Pramitha Yustia G99161073
 Patient Identity

Name : An. B
Age : 1 yo
Gender : Female
Religion : Islam
Address : Delanggu, Klaten
Inward : 5 July 2017
Examined : 6 July 2017
 Main Complaint

Stiffness in movement of left manus regio

 Recent Medical History
5 monthss before, when she
played around her house.
She suddenly crash the table That accident directly injured her
so that a bucket of hot water hands, abdomen, and legs. After
fell to her. that she was taken to PKU
Delanggu hospital for treatment

In the hospital, she was Two months ago, her family

treated for a week then
the medication of the
wound continued in the
house by nurse from RS
PKU Delanggu
felt worried because her hand
became stiff and can not be
straightened, so she got the
first operation to release
contracture in Kasih Ibu
hospital, and then skin graft
for her right hand in RSDM

Now, she will do

treatment for the left
hand
 Previous Medical History

Burn Injury history : (+) 5 months ago

Cardiac disease History : Denied
Allergic/asthma history : Denied
 Systemic Anamnesis

Eye : Jaundice (-), Blurred vision (-), double vision (-)

Ear : blood (-), buzzing hearing (-), hearing loss (-)
Mouth: bleeding gum (-), mouth sore (-), dry mouth(-)
Nose: secrete (-), blood (-)
Respiration: nasolalia (-), tight chest (-)
Digestion: nausea (-), vomit (-), pain (-)
Musculosceletal: pain (-), athralgia (-), stiffness (+) left
hand
 Genitourinaria: hematuria (-), pain (-)
Upper limb: tremor (-), sikatriks (+/+), cold extremity(-
) pain (-), athralgia (-)
Lower limb: tremor (-), sikatriks (+/+), cold extremity(-
) pain (-), athralgia (-)
Integument : pain (-), itch (-)
 Physical examination

Primary survey
Airway : Free
Breathing : Spontaneus breathing, thoracoabdominal,
RR: 24x/minute
Circulation: BP 110/70 mmHg, HR: 88x/minute
Disabilty : GCS E4V5M6, lateralization (-)
Exposure : t: 36,5 degree, sikatriks (+)
 Secondary survey
Head : Mesocephal (-), wound (-)
Eye : pale conjunctive (-/-), icteric sclera (-/-), Isocore pupil
(3mm/3mm), light reflex (+/+), periorbital hematome (-)
Ear : Mastoid pain (-), tragus pain (-), blood (-)
Nose : secrete (-), blood (-), deformity (-)
Mouth : wound (-), shaky mandible (-), shaky maxilla (-)
Neck : thyroid enlargement (-), lymphnody enlargement (-),
Thorax: normochest, symmetric, wound (-)
 Pulmo :
Inspection : symmetric
Palpation: fremmitus symmetric, pain (-)
Percussion: sonor/sonor
Auscultation : vesiculer base sound (+/+), addition sound (-)
Heart :
Inspection : ictus cordis not visible
Palpation : ictus cordis not palpable
Percussion: border enlargement (-)
Auscultation: regular, heart sound I-II, murmur (-)
 Abdomen:
Inspection : distended (-), sikatriks (+)
Auscultation: gut murmur (+)
Percussion : tympani
Palpation : pain (-) muscular defence (-)
Genitourinaria : pain (-)
Musculosceletal: pain (-), limited ROM at left hand
Extremity :
Upper limb : oedem (-/-), cold extremity (-), pain (-), sikatriks
(+/+)
Lower limb : oedem (-/-), cold extremity (-), pain (-), sikatriks
(+/+)
 Local Status

Left Manus Region:

Look: deformity and contracture at digiti I-V
Feel : Pain in movement (-)
Movement: active and pasive ROM limited
 Assesment I

Digiti I-V manus sinistra contracture et causa

combustio
 Planning I
Laboratory blood test (6 July 2017)
Hb : 11.3 g/dL
Hct : 39 %
AE : 5.62 million 106/uL
AL : 15 thousands 103/uL
AT : 342 thousands 103/uL
Blood type :O
PT : 13 seconds
APTT : 33,4 seconds
INR : 0,96
 Assesment II

Digiti I-V manus sinistra contracture et causa

combustio
 Planning II

Consultation to plastic surgeon Pro release

contracture
plain X-ray manus AP/Oblique
 Contracture and Burn Injury

Definition
Contracture defined as an inability to perform full range
of motion of a joint.
Burn Injury defined as loss of tissue because of thermal
injury such as heat, cold, electricity, radiation, chemical
trauma, and friction.
 Contracture post-burn injury
Contracture still become complicated problem of burn
injury. Wound that happens around shoulder is one of
particular problem needs to resolve.
Burn injury that happens at axilla can lead to disfunction
of shoulder abduction
 Classification

I : there is symptomp without disfunction of ROM

II : there is little reduction of ROM without disruption
activity of daily living
III : there is reduction of function with early change of
normal architecture in involved area
IV : loss of function of involved area
 Etiology

Thermal injuries
Chemical injuries
Electrical injuries
Post trauma (Volkmanns)
Buruli ulcer
Idiopatic (Dupuytrens)
Congenital (Camptodactyly)
Diagnosis in Burn Scar Contractures

1. Distinguish between soft tissue contracture and ankyloses of the

joint
2. Distinguish between connective tissue contracture and myogenic
or neurogenic contracture
3. Determine the difference diagnosis of contracture from the
anatomical structure :
- cutaneous, subcutaneous or facial contracture
- tendon contracture
- ligament contracture
- muscle contracture
4. Evaluate and classify the burn scar contracture to decide the
therapy
5. Evaluate functionally and esthetically before and after therapy
on the joint or the tissue
The Pathophysiology of Contractures

The contraction of Myofibroblast cause the wound

shrink (followed by deposisition of the collagen that
interconnected to maintain the contraction)
In embryogenesis stage, failure differentiation can
cause scarring that cause proximal flexi of the
interphalangeal joint that cause camptodactyly.
Prevention and Management of Burn
Scar Contractures

Prevent the contractures by spalk the burned area in

anatomic position and tell the patient to train the
joint to move
There are several things to be considered in
determining the management of contractures, such
as :
- patients social life and work
- patients psychological status
- patient motivation
 Conservative Treatment in
Contractures Management

1. Position that prevent contractures

The position should start at the first day until several months
after trauma
The patient rested in comfortable position, usually in flexi
position that is also the contracture position.
Positions that can prevent the contractures based on the burns :
a) Front neck
The positions that can cause contracture are neck flexion, chin
pulled to the chest, neck contour disappears
The positions that can prevent contractures are neck extension,
no pillow underneath the head, turning swivel neck, head tilted
during sitting position
positions that can positions that can
cause contracture prevent contracture
b) Back of the neck
Positions that can cause contractures are neck
extention and another neck movements
Positions that can prevent contractures are sitting in
flexion neck position, laying down on pillow
underneath the head
Contracture at the Positions that can
back of the neck prevent contractures
c) Anterior axilla, posterior axilla or axillary fold
Positions that can cause contractures are the limited abduction
and also protacted when the chest burns
Positions that can prevent contractures are laying down or
sitting with the arm abduction 90 degrees that supported by
pillow or other instrument between the chest and the arm
Positions that can
Contracture at axilla prevent contractures
d) Front elbow
Position that can cause contractures is elbow flexion
Position that can prevent contractures is elbow
extension
Contractures at the Position that can prevent
elbow contractures
e) Back of the hand
Positions that can cause contractures are
hyperextension metacarpalphalangeal (MCP),
interphalangeal flexion (IP), Thumb adduction and
wrist extension
Positions that can prevent contractures are extension
of the wrist in 30-40 degrees, MCP flexion in 60-70
degrees, IP extension and thumb abduction
Contractures at Positions that can
the back of the prevent
hand contractures
f) Palm
Position that can cause contractures is adduction and
flexion of the fingers
Positions that can prevent contractures are wrist
extension, minimal flexion of MCP, extension and
abduction of the fingers
Contractures at the palm Positions that can prevent
contractures
g) Back of the knee
Position that can cause contractures is knee flexion
Position that can prevent contractures is leg extension in
laying down and sitting position
Position that can prevent
Contractures at the back of
contractures
the knee
h) Feet
Feet are complex structure that can be pulled to any
different way by the healing tissue. This can cause
abnormal mobility
Positions that can prevent contractures are ankle
positioned in 90 degrees toward the soles of the feet
using a pillow to maintain the position. If the patient
is in sitting position, the position of his feet flat on the
floor (without edema)
Contractures at the feet Positions that can prevent
contractures
i) Face
Contractures of the face can include a variety of things
including disability to open or close the mouth perfectly,
disability to close eyes perfectly and etc.
Positions that can prevent contractures are by changing
face expression regularly and stretching the face. A soft
tube can be put into the mouth to prevent mouth
contractures
j) Groin
Position that can cause contractures are flexion and
adduction at the groin
Position that can prevent contractures are laying on
the stomach with leg extension, avoid sitting and
laying down in side position. In supine position, laying
down with leg extension position without pillow
underneath the knee
Position that can cause Position that can prevent
contractures contractures
2. Spalk
Spalking is very effective way to prevent contracture
and needed for comprehensive rehabilitation. Spalking
maintains a position that can prevent contracture
especially patient with great pain, and great burn injury
3. Stretching and early mobilization
The joint with burn injury should be stretched and
mobilized everyday
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