In a child with post‑burn contracture, when is surgical release indicated and what are the recommended pre‑operative assessment, pediatric anesthesia considerations, reconstructive options, and postoperative care?

Post-Burn Contracture Surgery in Pediatric Patients

Indications for Surgical Release

Surgical release is indicated when post-burn contractures cause functional impairment, restrict range of motion during activities of daily living, or involve critical anatomical areas including the axilla, hand/wrist, neck, face, feet, or flexure lines. 1, 2

Specific Surgical Triggers

• Contractures limiting shoulder mobility during functional tasks (reaching overhead, hand-to-head movements, toileting activities) warrant surgical intervention 2
• Axillary contractures are the most common site requiring release in pediatric patients, followed by hand/wrist and head/neck regions 1
• Children require additional releases during growth spurts due to differential growth rates between normal skin and scar tissue 1
• Functional impairment takes priority over cosmetic concerns when determining surgical timing 1, 2

Pre-Operative Assessment

Essential Evaluation Components

• Range of motion assessment during specific functional activities: high reach tasks, hand-to-head movements (combing hair), and hand-to-back pocket movements (toileting) to quantify functional limitation 2
• Scar tissue depth and extent must be mapped to determine whether simple release with grafting versus total scar excision is required 3
• Adjacent tissue availability for reconstruction planning, including assessment of unaffected skin near the contracture site 1
• Growth stage documentation in pediatric patients, as children in active growth phases may require staged procedures 1
• Previous surgical history including number and timing of prior releases, as this predicts recurrence risk 1, 4

Donor Site Planning

• Identify potential donor sites for full-thickness skin grafts (preferred) or split-thickness grafts 1
• Preserve donor areas for possible future procedures, particularly important in children who may need multiple releases during growth 3

Pediatric Anesthesia Considerations

Pain Management Protocol

• General anesthesia is required for contracture release surgery due to the extreme pain associated with these procedures 5, 6
• Titrated intravenous opioids and ketamine should be prepared, as ketamine is particularly effective for burn-related pain and reduces morphine requirements 5, 7
• Short-acting opioids are preferred for intraoperative management 5

Hemodynamic Considerations

• Ensure adequate fluid resuscitation and hemodynamic stability before proceeding with surgery 6
• Airway, breathing, and circulation must be secured prior to any surgical intervention 6
• Alpha-2 receptor agonists should be avoided in the perioperative period due to hemodynamic effects 5

Environmental Requirements

• Surgery must be performed in a clean environment with strict infection-control measures 6
• Tetanus immunization status must be verified and updated before surgery 6

Reconstructive Options

Graft Selection Algorithm

Full-thickness skin grafts should be used preferentially over split-thickness grafts for contracture release in pediatric patients. 1

Full-Thickness Skin Grafts (First-Line)

• Associated with significantly fewer re-release procedures compared to split-thickness grafts (p < 0.048) 1
• Longer interval between initial release and first re-release compared to split-thickness grafts 1
• Superior patient satisfaction regarding texture and color match 1
• Recommended for 63% of contracture releases based on 10-year outcome data 1
• Comparable donor-site morbidity to split-thickness grafts 1

Split-Thickness Skin Grafts (Alternative)

• May be used when full-thickness grafts are not feasible due to limited donor sites 1
• Higher recurrence rates and shorter time to re-release 1
• Used in 20% of contracture releases in large series 1

Advanced Techniques for Severe Multiple Contractures

• Dermal regeneration template (Integra) with total scar tissue excision can be considered for simultaneous release of multiple severe extensive contractures 3
• This approach reduces the number of operations and treatment duration (approximately 15 weeks for multiple sites) 3
• Provides limited donor-site morbidity while preserving donor areas for future procedures 3
• Particularly valuable when multiple anatomical regions require simultaneous reconstruction 3

Site-Specific Considerations

• Axillary contractures: Release improves shoulder flexion and reduces compensatory movements during functional activities 2
• Foot contractures: Both split-thickness and full-thickness grafts show 15% overall recurrence rate, but postoperative immobilization is critical 4
• Hand/wrist contractures: Require meticulous technique due to functional importance 1

Postoperative Care

Immediate Post-Operative Management

• Postoperative immobilization using dynamic or adynamic splints is mandatory to prevent graft loss and decrease contracture recurrence 4
• Wounds should be cleansed with tap water, isotonic saline, or antiseptic solution 5, 6
• Dressings must be selected based on wound appearance and patient condition 6, 8

Wound Care Protocols

• Avoid prolonged use of silver sulfadiazine as it is associated with delayed healing in superficial wounds 6, 8
• Antiseptic dressings may be appropriate for large or contaminated surgical sites 6
• Dressings should be reassessed and changed daily 6
• Circumferential dressings must not create tourniquet effect; monitor distal perfusion 6

Pain Management

• Continue titrated analgesia postoperatively, as dressing changes remain extremely painful 5
• Short-acting opioids and ketamine are optimal for procedural pain during dressing changes 5
• Non-pharmacological techniques including virtual reality or hypnosis may reduce pain intensity and anxiety 5

Long-Term Follow-Up and Rehabilitation

Intensive physical exercise (IPE) programs should be implemented as adjunct therapy to reduce the need for re-release surgeries. 9

• IPE decreases the frequency of contracture-release surgeries by approximately 60% (12.5% re-release rate with IPE versus 31.8% without IPE, p < 0.05) 9
• Exercise programs increase strength, lean body mass, aerobic capacity, and range of motion 9
• Functional improvements after axillary release are maintained for at least 12 months postoperatively 2
• Majority of improvement involves shoulder flexion, with decreased compensatory movements 2

Monitoring for Recurrence

• Children require closer surveillance during growth spurts for contracture recurrence 1
• Regular range-of-motion assessments during functional activities should be performed 2
• Early intervention for recurrence may prevent need for extensive re-release procedures 1

Critical Pitfalls to Avoid

• Do not delay surgery until multiple contractures develop; early intervention for functional impairment improves outcomes 1, 2
• Do not use split-thickness grafts when full-thickness grafts are feasible, as this increases re-release rates 1
• Do not omit postoperative splinting, as immobilization is essential for preventing graft loss and recurrence 4
• Do not perform surgery without adequate anesthesia and pain control, as contracture release is one of the most painful procedures 5, 6
• Do not neglect physical therapy and exercise programs postoperatively, as IPE significantly reduces re-release frequency 9
• Do not use topical antibiotics prophylactically; reserve for documented infection 6