BURN SURGERY AND RESEARCH

Factors Affecting Burn Contracture Outcome

in Developing Countries
A Review of 2506 Patients
Lauren P. Garcia, MS,* Alice Huang, MD, MBA,* Daniel Scott Corlew, MD, MPH,† Kush Aeron, MD,‡§||
Yogi Aeron, MD,‡|| Shankar Man Rai, MD,¶#** Goran Jovic, MD,††‡‡ and Richard L. Agag, MD§§

virus infections.1 More than 95% of burn-related deaths occur in

Introduction: Burn contractures hinder joint mobility, resulting in functional im-
developing countries with more than 50% taking place in South
pairment and reduced quality of life. This is of greater significance in developing
Asia alone. Burn injuries are frequently a function of poverty, and
countries where there are fewer resources for assistance with such impairments.
those especially at risk are children younger than 5 years and women
Contracture release reduces deformity, but multiple factors affect the extent of
of low-income countries, as well as elderly of any country.1–11 High
postsurgical improvements and outcomes. Elucidating these factors may enable
incidence of burns in low-income countries is attributed to unsafe
surgeons to better care for burn patients. This study assesses factors that impact
food preparation techniques such as floor-level cooking, improper
burn contracture resolution in developing nations.
storage of kerosene, and lack of physical barriers and supervision,
Methods: A retrospective review of 2506 burn contractures was performed using
all of which create dangerous situations in the household.9 Maternal
information extracted from a large nongovernment organization (ReSurge Inter-
education level and knowledge of burn-risks affect children's vulner-
national) database from Nepal, India, and Zambia. Data points included age, type
ability.1 Elderly are at greater risk because they are more prone to
of burn, time elapsed between injury and release, and extent of final release
any injury due to age-related cognitive and balance alterations, and
achieved based on preoperative and postoperative images of hand (n = 1960), el-
diminished coordination.1
bow (n = 371), and knee (n = 176) contractures. Hand improvement was scored
Burn injuries are a leading cause of injury and disability
based on digit/wrist involvement (severity of dysfunction) and joint extension ca-
among children in developing countries.12 Pediatric populations
pability (functionality); elbow and knee improvement were calculated using pre-
comprise most of the burn injury victims in previous studies conducted
operative and postoperative joint angles. Multivariate analysis was performed.
in Zambia,13,14 Iran,15 South Korea,16 Ecuador,7 Ghana,17,18 Saudi
Results: Hands burned by hot liquid had greater functionality after surgery than
Arabia,19 and Yemen.20 Children are readily exposed to open fire and
open-fire burns (P < 0.01). Improvement in severity of dysfunction and function-
hot or flammable liquids found in the kitchen, fireworks during fes-
ality were inversely correlated to age (P < 0.01) and time until surgery (P < 0.01).
tivals, and common heated herbal remedies for childhood illnesses,
Elbow improvement decreased as age increased (P < 0.01). Postoperative in-
all of which predispose them to burn accidents.21,22 Children tend
crease of knee extension decreased for each year elapsed between injury and
to experience more serious burns and complications from their injuries,
surgery (P < 0.01).
such as hypertrophic scars and burn contractures, due to their thin
Conclusions: Burn type, age when burned, and timing of surgery were signifi-
skin,17,23–25 making them more likely to require reconstructive surgery.26
cant factors affecting hand outcomes, whereas age affected elbow outcomes,
Burn depth is the most important factor in terms of the extent of
and time elapsed until surgery affected knee results. An algorithm was formulated
injury. In turn, depth of a burn depends on multiple factors, including
to enable physicians in developing countries with limited resources to triage pa-
duration of exposure, temperature of the energy source if the burn is
tients and optimize patient outcomes.
thermal, and skin thickness, which varies by body location as well as
Key Words: burn, burn contracture, contracture release, knee contracture, age, with the young and elderly having thinner skin than their middle-
elbow contracture, hand contracture aged counterparts. Viscosity in hot liquid burns tends to increase the du-
(Ann Plast Surg 2016;77: 290–296)
ration of exposure, worsening the injury. Finally, whether the burn is
due to heat from convection, from liquids, or from chemicals (acidic
or basic substances) affects the nature of the injury. Excess tension pro-
W orldwide, burns are a leading cause of mortality among children
and young adults age 5 to 29 years, and cause a higher inci-
dence of injury than tuberculosis or human immunodeficiency
motes inflammation, delays scar maturation, and may stimulate excess
contraction of myofibroblasts, resulting in contracture or hypertrophic
scar formation. Conservative or expectant management of partial- and
full-thickness burns with late excision and grafting promotes contrac-
ture formation as epithelium seeks epithelium in the healing process.27
Received September 7, 2015, and accepted for publication, after revision May Contracture formation can be attributed to healing of deeper tissues in-
17, 2016.
From the *Albany Medical College, Albany, NY; †Middle Tennessee Medical Center, volved in the burn or from contraction of a skin graft during the acute
Murfreesboro, TN; ‡Helping Hands Hospital; §Uttarakhand Medical & Health stages of burn care.28
Department; ||ReSurge International, Dehradun, India; ¶National Academy of Long-term burn care is extensive and costly, making optimal
Medical Sciences; #Kirtipur Hospital; **ReSurge International, Kathmandu, care less feasible in low-income countries where supplies and resources
Nepal; ††University Teaching Hospital; ‡‡ReSurge International, Lusaka,
Zambia; and §§Albany Medical Center, Albany, NY. are often limited. Even with the addition of external humanitarian aid,
Abstract presented at NYRSPS Residents' Night 2015 and at the ASPS Meeting 2015 access varies greatly based on timing and geographic location. In high-
with subsequent abstract publication in PRS special supplement issue (Garcia LP, income countries, burn treatment involves early intervention wound
Huang A, Corlew DS, Agag RL. A prospective review of 2506 burn contractures care,29,30 early excision and skin grafting,31 medication,30,32 pain
in developing countries: factors affecting improved function. Plast Reconstr Surg.
2015;136(4 Suppl):147–8). control,30 splinting, pressure garments, and physical therapy.30,33,34
Conflicts of interest and sources of funding: none declared. Early grafting can decrease the likelihood of developing a burn con-
Reprints: Richard L. Agag, MD, Albany Medical Center, 43 New Scotland Ave, MC tracture35; however, the more total body surface area burned, the
190 Albany, NY 12208-3479. E-mail: richardagagmd@gmail.com. greater the risk of scar contracture formation.23 Use of splints and
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0148-7043/16/7703–0290 pressure garments before surgery may improve joint mobility30 and de-
DOI: 10.1097/SAP.0000000000000856 crease surface area of the wound.36 Even with intensive initial treatment

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Annals of Plastic Surgery • Volume 77, Number 3, September 2016
TABLE 1. Patient Demographics
Hand Knee/Elbow
Age, y 0–79 0–65
Median age, y 10 10
<18 years old 79% 76%
Median time interval between burn and surgery, y 6 4
Cause of burn
Open fire 77%
Hot liquid 17%
Other 6%
and advanced follow-up care, contractures may still develop—up to
38.7% of elbow, knee, or shoulder37 burns and up to 44% of hand38,39
involvement still result in contracture.
Secondary burn reconstruction consists of scar contracture release
performed by tissue rearrangement, skin grafting, or local/regional flaps.
With the exception of complex reconstruction with free flaps, secondary
reconstructive procedures are similar in developing and developed
countries. Burn contractures of the hand resulting in syndactyly or
involving web space are treated with excision followed by local flaps
or skin grafting, whereas more extensive deformities may require ex-
tensive skin excision, coverage by full-thickness skin grafts, and of-
ten tendon repair/transfer.40 Those limited to the digits may be
resolved by Z-plasty alone.41 Elbow and knee contractures may be
treated with either Z-plasty or excision plus skin grafting; however,
deeper burns often require local or regional flaps after excision for
coverage of exposed bone/tendon.28,42
Burn victims experience both physical and psychological ef-
fects from their injuries. Loss of tactile sensation,43 pain, and in-
creased cardiac output44 increase the risk of subsequent injury and
comorbidity. Loss of limb function—particularly as a consequence
of contracture formation—results in decreased contribution to soci-
ety. Burn scars can result in higher rates of unemployment,45 de-
creased opportunity for education,20 low self-esteem,46 episodes of
aggression,47 and mental disorders,48,49 contributing to difficulties inte-
grating into a community50 and overall decreased quality of life.51,52
These types of outcomes are especially prevalent in low-income
countries where few people receive adequate acute care, resulting
in disability rates 12.5 times higher than in high-income countries.1
Contracture release surgery can be invaluable in relieving the socio-
economic burden of burn-related injuries by improving disability
and, therefore, quality of life. Elucidating factors that improve out-
comes of burn contractures after release surgery will enable burn
surgeons and international organizations to provide better care to
burn victims, particularly in developing countries where there is
greater demand for such changes. The purpose of this study was to
investigate the influence of patient age, time elapsed between the ini-
tial burn and subsequent surgery, and the type of the burn sustained
on the outcome of burn contracture release surgery.
FIGURE 1. Scale of burn contractures of the hand: preoperative and postoperative SOD.
© 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
A Prospective Review of 2506 Burn Contractures
METHODS
A retrospective review was performed using the database of
one of the programs of the NGO ReSurge International [ReSurge In-
ternational (formerly Interplast) is a nongovernment organization
that provides reconstructive surgical care in developing countries
for children and adults who lack access. Resurge works in 15 coun-
tries with 12 permanent surgical outreach programs in 8 of them, in-
cluding Nepal, India, and Zambia]. This program provides a capitated
global fee to the surgeon for burn contracture release. This included
data on 2506 patients from January 2004 to July 2012 who underwent
burn contracture release surgery for the hand (ie, digits and wrist)
(n = 1959), knee (n = 176), and elbow (n = 371) in Nepal, Zambia,
and India. Snake bites resulting in tissue necrosis similar to that seen
with burn injuries were included in the database and in this study.
Contracture release in our study includes a broad range of surgical
techniques implemented for excisional debridement or rearrange-
ment of scar tissue after burns; most releases were performed by
scar excision with skin grafting and/or local tissue rearrangement
(ie, Z-plasty/W-plasty). Demographic information collected in-
cluded location of injury, patients' country of habitation, patient
age, time interval between the burn incident and contracture re-
lease surgery, and cause of the burn (Table 1). Preoperative and
postoperative images of the affected joint were included in the da-
tabase and were used to generate a score for severity of dysfunction
(SOD) and functionality for each patient. Photographs have been
found to be an effective method for grading burns53 and are used
by many burn therapists.54
Patient age ranged from younger than 1 to 79 years. Seventy-
nine percent of hand contracture and 76% of knee/elbow contracture
patients were younger than 18 years. Median time waited between burn
injury and contracture release surgery was 4 years for knee and elbow
joints, and 6 years for hand and wrist joints. Types of burn included
in the study were open fire (79% of hand, 71% of knee and elbow),
hot liquid (14% of hand, 29% of knee and elbow), chemical burn
(0.2% of hand), acid (5.2% of hand), and snake bite (1.2% of hand).
Severity of dysfunction of the hand in preoperative and post-
operative images was graded on a scale of 1 to 5, with 5 being the
most severe, based on the number of digits involved in the burn con-
tracture, and participation of the wrist in the injury. Grading spe-
cifics are outlined in Figure 1.
Functionality of the hand, which we define as joint extension ca-
pability of the digits and wrist, was assessed using postoperative images
then graded on a scale of 1 to 5, 5 being the most functional (Fig. 2).
Degree of movement attainable by extension of the fingers was also
factored into the grading system. Grade 1 represented a nonfunctional
hand, with only 1 digit capable of extension. Grade 3 represented a hand
with pincer capability. Grade 5 represented a fully functional hand (5 fin-
gers with full extension capability) and complete wrist extension.
Improvement from surgical intervention for the elbow and
knee was calculated using the difference between preoperative and
postoperative angle of maximum extension of the joints. A score
ranging from 1 to 5 for degree of improvement was assigned to each
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Garcia et al Annals of Plastic Surgery • Volume 77, Number 3, September 2016

FIGURE 2. Scale of burn contractures of the hand: postoperative functionality.

patient: a change in joint angle of 0 to 20 degrees was scored 1, demon-
strating a low degree of improvement; whereas a change of 81 to 100 de-
grees was scored 5, signifying a high degree of improvement.
Only patients who underwent surgical release and whose
charts contained complete demographic data and clear preoperative
and postoperative images were included in the study. No other spe-
cific exclusion criteria were implemented. Multivariate analysis
was performed on the collected data using STATA 11 software. Sta-
tistically significant postoperative improvement in the unadjusted
data was then adjusted for patient age and for the time interval be-
tween the injury and the contracture release to assess the individual
impact of each factor on patient outcome. Statistical significance in
this study is defined as a P value less than 0.01.
RESULTS
The Hand
Cause of burn, patient age, and time interval between the burn
and surgery were all statistically significant factors affecting postsurgi-
cal improvement of SOD (Table 2) and functionality (Table 3).
Preoperative SOD was greatest in chemical burns (grade 3.8),
followed by snake bites (3.3), hot liquid (2.9), open fire (2.6), and acid
(1.9). Burns involving 2 to 3 fingers plus or minus the wrist (grade
3) were most common (36%). Ninety-eight percent of all hand contrac-
tures showed improvement after surgical release.
Postoperative SOD was lowest in chemical, acid, and snake bite
burns, and every patient in these categories showed improvement from
preoperative values, with more than 85% of patients having no finger or
wrist involvement after surgery (grade <1). Hot liquid and open fire
injuries comprised most of the contractures studied and had the least
improvement after release. Data analysis is therefore focused on
these 2 types of burns, and they seem to have the greatest potential
for improved outcomes (Table 2). Hands burned by hot liquids
benefited more from surgical intervention than hands burned by
open fire (P < 0.01).
Improvement in SOD was inversely correlated to patient age
(P < 0.01) and time interval between injury and surgery; as both of these
variables increased, postsurgical outcome invariably worsened. Statisti-
cally significant improvement was seen specifically with preoperative
SOD grade 3 (0.23 ± 0.07 more functionality, P < 0.01) when adjusted
for increased time interval, and with preoperative SOD grade 4
(0.56 ± 0.14 greater functionality, P < 0.01) when adjusted for age.
For every 1 year increase in age, improvement in SOD and function-
ality after surgery both decreased by 0.01 ± 0.002 (P < 0.01). For ev-
ery year surgical intervention was delayed after injury, improvement
in SOD decreased by 0.02 ± 0.002 (P < 0.01) and degree of postop-
erative functionality decreased by 0.01 ± 0.003 (P < 0.01). The
greater the length of time elapsed until contracture release had the
largest negative impact on patient outcome.
Hands burned by hot liquid had significantly more postoperative
functionality than hands burned from open fire (P < 0.01) for preoper-
ative grades 3 and 4 when adjusted for the age of the patient (Table 3).
In patients with greater initial function (preoperative grade ≥3), level
of postoperative functionality decreased with increasing patient age
(P < 0.01) and increasing time interval between the burn and surgery
(P < 0.01). Older age had the greatest detrimental effect in improve-
ment of functionality for patients with preoperative SOD grade 4.
Patients whose preoperative SOD was lowest (grades 1 and 2) showed
no statistically significant improvement in hand function after contrac-
ture release; furthermore, neither age nor time elapsed affected the out-
come of these patients.
The Elbow
Injuries sustained from open fire had worse overall outcomes for
the elbow when compared to burns suffered from hot liquid (Table 4).
Patient age was a statistically significant factor affecting surgical out-
come of the elbow. After adjusting for time elapsed and type of burn,
for every 1 year increase in age, improvement from contracture release

TABLE 2. Factors Affecting Improvement in SOD of the Hand After Surgery Stratified by the Preoperative SOD

Improvement in SOD (of Hot Liquid Time Interval Between

Burns Minus Open Fire Burns) Age of Patient, y Burn Injury and Surgery, y
Preoperative SOD n Difference in SOD SE P Effect on Improvement SE P Effect on Improvement SE P
1 329 0.0060 0.041 0.88
2 425 0.091 0.059 0.13
3 Unadjusted 659 0.24 0.065 <0.01 −0.011 0.0024 <0.01 −0.019 0.0029 <0.01
Adjusted for time waited 659 0.16 0.065 0.01
4 Unadjusted 315 0.66 0.14 <0.01 −0.033 0.0059 <0.01 −0.036 0.0073 <0.01
Adjusted for age 315 0.49 0.14 <0.01
5 88 0.64 0.49 0.19
Unadjusted −0.017 0.0023 <0.01 −0.022 0.0028 <0.01
Statistically significant relationships are bolded.

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Annals of Plastic Surgery • Volume 77, Number 3, September 2016 A Prospective Review of 2506 Burn Contractures

TABLE 3. Factors Affecting Postoperative Degree of Functionality of the Hand Stratified by Preoperative SOD

Postoperative Functionality (of Hot Liquid Time Interval Between

Burns Minus That of Open Fire Burns) Age of Patient, y Burn Injury and Surgery, y
Difference in
Preoperative SOD n Degree of Functionality SE P Effect on Improvement SE P Effect on Improvement SE P
1 329 −0.022 0.067 0.74
2 426 0.12 0.067 0.068
3 Unadjusted 656 0.28 0.065 <0.01 −0.012 0.0024 <0.01 −0.015 0.0031 <0.01
Adjusted for time waited 656 0.23 0.067 <0.01
4 Unadjusted 314 0.63 0.14 <0.01 −0.30 0.0060 <0.01 −0.037 0.0073 <0.01
Adjusted for age 314 0.57 0.14 <0.01
5 0.57 0.34 0.11 0.10
Unadjusted −0.0082 0.0021 <0.01 −0.013 0.0026 <0.01
Statistically significant relationships are bolded.

decreased by 0.36 degrees ± 0.13 (P < 0.01). Degree of improvement
was most negatively affected by open fire (−0.36 ± 0.12, P < 0.01),
and by patient age (−0.008 ± 0.0052, P < 0.01).
The Knee
Open fire burns to the knee fared significantly worse than
those sustained with hot liquid (Table 5). After adjusting for the
other 2 variables, time interval between the burn and surgery signif-
icantly impacted patient outcome for each additional year elapsed
until surgery, postoperative change in extension decreased by 1.25 de-
grees ± 0.35 (P < 0.01). Age also proved to be a factor significantly
impairing degree of improvement of the knee (−0.015 ± 0.005, P < 0.01).
DISCUSSION
More than three quarters of burn contracture release patients
in this program are younger than 18 years, consistent with the
literature.13–20 Additionally, this age group is faced with lifelong dis-
ability, which means functional impairment for a larger proportion of
years lived than people who are older at the time of injury. Our data
as well as others55 indicate that children have the best outcomes after
contracture release. These combined elements suggest that young peo-
ple have the most to benefit from contracture release surgery.
Ideally, every person with a contracture as a result of previous
burn injury would have access to surgical intervention; unfortu-
nately, this is not the case, particularly in developing countries where
access to reconstructive surgery is limited. Instead, we support a
model in which overall return of functionality and long-term produc-
tivity of the patient is analogous to societal benefit. We aimed to
identify the factors affecting contractures and their management to
stratify outcomes to maximize patient improvement, and therefore
societal benefit, in resource-limited countries. From our data, we
created an algorithm and scoring system (BAT score, for Burn type,
Age, and Time interval between burn injury and release) for burn
contracture patients that can be used to identify patients who are
most likely to experience a favorable outcome from surgical inter-
vention. This is similar to current renal transplant priority that strat-
ifies patients not based on severity of disease, but rather by HLA
match and proximity to organ procurement site, both of which con-
fer greater potential for transplant success.56 Moreover, we recog-
nize that many burn injuries may not require the specific skillset of
a plastic surgeon; many of these contracture releases can be performed
by appropriately trained general surgeons, thus reserving cases requir-
ing a specialized surgeon for the limited plastic surgeons available.
Stratification of patients is based on factors affecting contracture out-
come objectively identified in our study—type of burn, patient age,
and time elapsed since the burn injury—as well as preoperative SOD.
Our data showed greatest improvement in SOD and functionality
after surgery in hands burned by hot liquids. Seventy-three percent of
patients burned by hot liquid had full functionality restored by surgery,
compared to only 6% of those burned by open fire. More than 85% of
patients with contractures from snake bites, chemical, or acid burns had
no finger or wrist involvement after surgery (grade <1). Further, postop-
erative pincer grasp was restored in every patient who experienced
chemical or acid burn, whereas up to 6% of open fire burns and snake
bites gained no pincer ability from surgery. The algorithm shown in
Figure 3 can help health care providers triage burn contracture patients
to optimize outcome and use limited resources efficiently.
Further studies are needed to validate our evidence-based pro-
posed algorithm and BAT score, applying it to a similar population of

TABLE 4. Elbow Joints: Factors Affecting Extension and Degree of Improvement After Surgery

Change in Angle (Postoperative Angle Minus Preoperative Angle) Degree of Improvement

Joint Factor Coefficient SE P Coefficient SE P
Elbow, n = 371 Open fire minus −2.2 3.2 0.413 −0.36 0.12 <0.01
hot liquid
Age −0.36 0.13 <0.01 −0.008 0.0052 <0.01
Time waited −0.44 0.22 0.50 −0.012 0.0098 0.24
Statistically significant relationships are bolded.
The negative coefficients indicate that open fire had worse overall outcomes when compared to burns suffered from hot liquid for the elbow.

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Garcia et al Annals of Plastic Surgery • Volume 77, Number 3, September 2016

TABLE 5. Knee Joints: Factors Affecting Change of Angle and Degree of Improvement After Surgery

Change in Angle (Postoperative Angle Minus Preoperative Angle) Degree of Improvement

Joint Factor Coefficient SE P Coefficient SE P
Knee, n = 176 Open fire minus hot liquid −0.33 8.4 0.97 −0.13 0.22 0.54
Age −0.12 0.20 0.56 −0.015 0.0050 <0.01
Time waited −1.25 0.35 <0.01 0.015 0.0094 0.11
Statistically significant relationships are bolded.
The negative coefficients indicate that open fire had worse overall outcomes when compared to burns suffered from hot liquid for the knee.

patients, analyzing the outcomes, and comparing them to those in this
study. The algorithm and BAT scoring system would be validated if
we observe statistically significant improvement in SOD and function-
ality after surgery in the new population of patients.
Prompt surgical intervention after contracture development (ie,
at an earlier stage of scar formation) is necessary to maximize potential
future functionality. However, prolonged time interval waited (in our
study, a median of 4 and 6 years for elbow/knee and hand, respectively)
suggests poor access to surgical care for burn injuries. Another study
found a similar delay of 2.8 years before receiving contracture release
surgery.57 Lack of plastic surgeons in certain geographical locations is
a leading cause of failure to receive appropriate care during critical
initial phases of healing.58 Perceived cost is another common reason
for patients to delay care.57 In many low-income countries, primary care
physicians are the first-line medical personnel treating burn-related in-
juries, therefore they require training in initial care and follow-up for
burns.26 Considering the high incidence of burns in developing coun-
tries and the subsequent detrimental impact they have on finding/
maintaining employment,45 providing surgical intervention in the time-
liest manner possible after burn injury may profoundly decrease mor-
bidity and improve quality of life globally.
Improvement in SOD was observed in 98% of patients in this
study after contracture release surgery of the hand, knee, or elbow joint.
Burn contractures of the hand are especially debilitating due to the

FIGURE 3. Algorithm for stratification of burn contracture patients for surgical intervention and BAT scoring system.

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Annals of Plastic Surgery • Volume 77, Number 3, September 2016
involvement of the hand in activities of daily living (ADLs) such as
bathing and grooming38; pincer grasp, and therefore thumb function,
are critical to performing tasks such as writing, or ADLs.59 Although
the hand represents 3% of the total body surface area, a contracture of
this joint can cause 57% loss of entire body function.60 The elbow only
needs an arc of 30 to 130 degrees to perform most ADLs,61 indicating
that even mild improvement in elbow extension can be a large increase
in functionality. Therefore, improvement in SOD of hand and elbow
joints from surgery can dramatically improve quality of life and de-
crease socioeconomic burden attributed to burn-related incidents.
Just as surgical correction of cleft lip and palate can be done in a cost-
effective manner with a relatively small cost per disability-adjusted life
year in similar resource-limited populations,62–64 burn contracture release
may be similarly feasible.
The database used in this study is updated regularly with new
patient information collected by surgeons participating in the pro-
gram in different countries, resulting in variability of data based on
individual surgeons and distinct sites. Our study is limited by lack
of data on availability of and patient adherence to hand therapy and to
follow-up. Although follow-up is emphasized, it varies greatly depend-
ing on the patient's geographic location relative to the clinic, socioeco-
nomic factors, and transportation availability. Because hand therapy is
an integral part of recovery, postsurgical patients are given home exer-
cise programs; unfortunately, tracking therapy of each patient is not part
of the current database, making it difficult to determine how adherent
each patient is with either occupational therapy follow-up or home ther-
apy. Multivariate analysis was performed to minimize the effect of
confounding variables.
CONCLUSIONS
Ninety-eight percent of all hand contractures showed improve-
ment after surgical release, with greatest improvement (fewest number
of digits impaired) observed in chemical burns, acid burns, and snake
bites. Type of burn suffered, age at which the burn was sustained, and
timing of surgical intervention were significant factors affecting the out-
come of hand contracture release, whereas patient age affected elbow
outcome, and time elapsed until surgery affected knee results. This in-
formation can be used to stratify patients based on factors affecting burn
contracture surgical outcome, enabling physicians to triage patients to
optimize outcome and use limited resources efficiently.
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