TREATMENT OF POST-BURN SECONDARY FOOT DEFORMITY

A case of simultaneous correction of severe post-burn deformity with limited movement in the ankle joint, subluxation and contractures in the metatarsophalangeal joints in a 3-year old child is presented. Excision of scar tissues, tendinous plasty, capsulotomy of involved joints were performed. To close the defect, a full-thickness skin graft was used. In two years, no signs of recurrence were observed.

At present, despite the pronounced progress in the prevention and treatment of burns during childhood, burns still remain one of the leading causes of trauma and disability in children, particularly in young children. The problems associated with surgical treatment and rehabilitation of this category of patients represent some of the most important challenges in pediatric surgery, traumatology, and combustiology [1−6]. According to recent data, more than 40% of children with burn injuries need subsequent reconstructive surgeries.
Th e foot is one of the most common site of localization for burns. Even aft er adequate surgical treatment in the acute period aft er thermal injury, scars that form on the dorsum of the foot oft en lead to subsequent deformities. Th e foot is composed of a large number of small joints, a subtly organized tendon-muscular system, a relatively small amount of soft tissues, and the surface location of functionally important anatomical structures. Because of these factors, damaging agents have a great impact on the foot, with the early development of secondary pathological changes, resulting in disability in childhood cases. Th e most severe deformities are observed in children who were injured at an early age and who did not receive orthopedic care aft er the healing of burn injuries. High amount of stress on a foot undergoing gradual deformation results in the development of secondary bone deformities and progression of spatial relationship abnormalities in the joints. Th e long-term existence of a deformity results in the development of persistent pathological positions that are diffi cult to correct [3,4].
Th e lack of standards for the complex treatment of burns and for the prevention of post-burn deformities of the foot result in frequent disability and serious problems with social adaptation in children. In this case report, we observed that severe complications occur, thereby resulting in developmental abnormalities and problems concerning the child's social adaptation ability; these complications are associated with the young age of the child and long period since the formation of both deformities and contractures until treatment.
Reconstructive surgery for burn deformities is associated with two major goals; the fi rst goal is to restore the lost functions of the foot and the second goal is to improve the appearance of the patient as well as to provide psychological and social rehabilitation, which are oft en equally important [7−10]. Surgical rehabilitation of children with post-burn deformities remains a challenging and complicated fi eld of surgery [11,12].
Here, we present the case of a child with a post-burn deformity of the left lower extremity and subsequent treatment. According to the past medical history, the girl, born in 2007, was burned by hot water at the age of 1 year. She was diagnosed with heat injury of grade 2-3 on the left leg and foot. In the acute period aft er the injury, at a local medical facility, the child underwent skin graft ing on the left leg and foot, and some wounds healed on their own. Orthosis care was not provided to the child at the time of the initial treatment.
At the age of 3 years, the child was presented to our institute's clinic with complaints of rough cicatricial deformities of the left foot and toes, pain while walking, and diffi culty in choosing shoes. On admission, physical examination demonstrated that the child walked independently; however, she limped on her left leg, and the supporting ability of the left foot was reduced. Rough cicatricial deformities of the dorsum of the lower third of the left leg, ankle joint, and foot were observed. Plantar fl exion of the foot was limited because of the rough deforming scars in the ankle region. Th e toes were deformed, shift ed to the dorsum of the foot, and did not return to their anatomically correct position (Fig. 1). Subluxation was detected on performing an X-ray examination of the metatarsophalangeal joints (1-5) (Fig. 2).
Th e child underwent surgery, and dissection and partial excision of the cicatricial tissue of the dorsum of the foot and the underlying cicatricial tissues were performed. To remove the toes from the dorsifl exed position and place them in their anatomically correct position, surgery was supplemented with capsulotomy of the metatarsophalangeal joints (1)(2)(3)(4)(5) and simultaneous lengthening of the extensor tendons of the toes (1-5). Th us, these interventions resulted in the complete elimination of the toe extension deformity. The resulting wound was closed using Wolfe graft taken from the groin area and adapted to the wound topography as well as gauze balls. The toes were fixed in the corrected position using pins (toes 1-5) and by performing subsequent plaster immobilization. Postoperatively, the child was on strict bed rest for 14 days, with the operated extremity in a raised position. On day 14,  the gauze fi xation of the skin graft was removed. Assessment of the skin graft revealed that complete engraftment had occurred without any signs of necrosis. Th e child was then allowed to walk with crutches without weight bearing on the operated extremity. Th e pins were removed 3 weeks aft er the surgery. A stage splint of the corrected toe position was performed, and the patient was permitted to walk on crutches with partial weight bearing on the operated foot. Consequently, complete and persistent correction of the deformity was achieved with no evidence of a tendency to relapse in the last 2 years (Fig. 3). Furthermore, orthosis care for the child was recommended, including wearing splints at night for 6 months, wearing customized shoes, anti-scar therapy, and rehabilitation (remedial exercises and physiotherapy).
In conclusion, the possibility of one-stage correction of severe post-burn secondary deformity of the foot was demonstrated in this case using a full-thickness skin autograft plasty.