Classification and Approach to Surgical Management of Burn Contractures of the Toes

Background: Burn contracture of the toes is a common sequela of thermal injury to the foot often requiring complex operations addressing both skin and deeper tissues. Without proper treatment, patients experience functional limitations, inadvertent trauma to the deformed toes, and recurrent contractures requiring multiple reconstructive procedures. In this study, we define a new classification of toe burn scar contractures (TBSC) which will allow surgeons to tailor definitive surgical treatment based on the individual needs of the patient's condition.

Methods: A retrospective review was performed on 279 TBSC releases, completed on 20 patients from March 2000 to June 2010 at the University of Michigan. Based on contracture complexity, a classification system was developed to describe each TBSC as mild, moderate, or severe. Mild TBSC involved scarring of the superficial tissues only and were treated with scar excision or local tissue rearrangement. Moderate TBSC involved significant soft tissue deficits that required scar excision and resurfacing with skin grafts; these sometimes required ancillary procedures including closed capsulotomy of the metatarsal phalangeal or interphalangeal joints. Severe TBSC demonstrated significant involvement of deeper structures, including tendons and joint capsules, and required a patient-specific technique where each scarred component was addressed surgically.  Furthermore, severe TBSC often resulted in deformities requiring multiple procedures including skin grafting, tendon lengthening, open capsulotomy, and pin fixation.

Results: There were 6, 3, and 11 patients with mild, moderate, and severe TBSC, respectively, and mean age per group was 16, 16.7, and 10 years. The mean number of required primary procedures per toe increased with increasing burn complexity (1.1, 1.5 and 1.8), with severe TBSC requiring more primary procedures overall (13.7 in severe vs. 2.8 in mild TBSC) (Table 1). Secondary operations were only required with severe TBSC. Complication rates per toe followed the same trend (29.2%, 42.5%, and 59.0%) and included recurrent contracture, limited toe movement and growth, chronic pain, and webspace syndactyly. 40% of severe TBSC experienced major complications, requiring another operation, whereas no patient with moderate or mild types had major complications.

Conclusion: An individualized and comprehensive surgical approach based on TBSC severity is recommended for addressing burn contracture of the toes. Analysis of the specific structures involved allows for correct classification of the severity and dictates the surgical interventions necessary for satisfactory reconstruction.