title: Shoulder adduction contracture after burn: anatomy and treatment with quadrangular local scar subcutaneous pedicled flap, a new approach.
abstract: BACKGROUND
  Axillary adduction contracture is caused by scars that tightly surround the shoulder joint impairing the function of the upper limb. Due to severe scar surface deficiency, contracture release presents a challenge for surgeons since a method of release is transfer of tissue in the form of a large pedicled or free flap(s). Thus, development of simpler, less traumatic techniques, using local tissues, persists.
  
  
  METHODS
  Anatomic studies of shoulder adduction contractures after burn (pre-operative, during surgery, post-reconstruction) were done in 346 pediatric and adult patients. All were divided into three groups according to contracture types: with edge contractures (80%), medial (6%) and total (14%). Anatomical study covered peculiarities of total contractures and possibilities for their treatment using local scarred tissue.
  
  
  RESULTS
  Total contractures (48 patients) were caused by scars tightly surrounding the joint on three sides: anterior, posterior, and axillary. There were two specific forms of contracture: (a) shoulder close to the chest wall (22 of 48 patients) which was treated with thoracic pedicled or free flaps; (b) in 26 out of 48 patients a flat scar and skin graft surface laid along the shoulder and chest wall, in axillary projection, which were used for contracture release in the form of a subcutaneous pedicled quadrangular flap. The flap was mobilized only peripherally, descending to the apex of the axilla, forming the central axillary zone, and suspension of the axilla on a normal level. Wounds aside the flaps were covered with skin graft. Acceptable functional and cosmetic results were achieved in all 26 patients.
  
  
  CONCLUSIONS
  Total shoulder adduction contractures have two forms: (a) shoulder close/fused with the chest wall; and (b) along the chest wall and shoulder there is a flat surface, the tissue of which can be used for reconstruction in a form of scar subcutaneous pedicled quadrangular flap. Based on this flap, a new technique is described which is relatively easy to perform.
authors.affiliation: Department of Reconstructive and Plastic Surgery, A.V. Vishnevsky Institute of Surgery of the Russian Academy of Medical Sciences, Moscow, Russia. Electronic address: grishkevichmail@gmail.com.
authors.forename: Viktor M
authors.initials: VM
authors.lastname: Grishkevich
mesh_terms: D000293:Adolescent; D000328:Adult; D002056:Burns / Q000150:complications*; D002648:Child; D002675:Child, Preschool; D003286:Contracture / Q000145:classification / Q000209:etiology / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D016059:Range of Motion, Articular; D012782:Shoulder; D016038:Skin Transplantation / Q000379:methods*; D013524:Surgical Flaps; D055815:Young Adult
keywords: Contracture classification; Quadrangular scar flap; Scar contracture treatment; Shoulder contracture