Although contractures are preventable, the literature demonstrates that they can still occur in up to 80% of burn survivors, even in advanced and specialist burn services. To see a world without burn contractures, we can build on existing research and understanding of how and why contractures form, this will help us develop better prevention strategies. By connecting people from all backgrounds to raise awareness about burn contractures, we can work together to create a world without burn contractures.

how do they form?

Burn injuries can cause damage to the skin, underlying tissues, muscle, and even bone. As the body begins to heal after a burn, complex biological processes and pathways, required for wound healing are activated. The body begins to close open wounds by contraction and reducing their surface area.

As the healing process continues, some scar contraction can be normal. However, excessive scar production can occur. This is associated with persistent activation of fibroblasts and myofibroblast cells which cause scar production and wound contraction leading to scarring which if near or over a joint can form a contracture.  Further research is needed to understand the complex micro and macro processes behind burn contracture formation and how this relates to known risk factors. With this knowledge we can develop effective preventative strategies to stop contractures.

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Throughout the different stages of recovery from a burn injury many risk factors are at play from injury to scar maturation (around 2 years post injury); longer if the injury happens in childhood.

Risk factors for burn contractures:

Patient Related Factors 
This includes demographic factors such as age, gender, ethnicity, and personal characteristics such as occupation and socioeconomic status, level of family support and co-morbidities.

Medical or Surgical Treatment Factors

The medical and surgical treatments associated with increased risk of contractures include:

• Longer stays in the intensive care unit (ICU)

• Higher number of surgical procedures

• Lack of skin grafting

Rehabilitation Factors 
Interventions such as physiotherapy, splinting and pressure garments, silicone and scar massage contribute to long term rehabilitation for people with burns injuries and contracture prevention / treatment. .

Burn Related Factors

The mechanism, depth and initial management of a burn injury affects the risk of contracture formation. Contracture formation is more likely with:

• Deeper and full thickness burns

• Burns on a larger total body surface area (TBSA)

• Lack of appropriate first aid at time of injury

• Location of burns – burns over a joints

• Infection and longer healing times

• Inhalation injury

Health System Factors

Globally, people have varying access to healthcare. People who have difficulty accessing a healthcare facility either initially or for follow up post discharge demonstrate higher risk of contracture formation. People who can access specialist burn care will be less likely to develop contractures. The availability of specialist burn care in LMICs is very limited.

This is not an extensive list of risk factors, more research is needed to develop a comprehensive understanding of burn contracture risk and how these factors interact in different environments and settings.

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Every individual is different and has their own unique journey leading to and following a burn injury. Prevention and treatment efforts for burn contractures need to be tailored to the individual and their own experiences. With better understanding, we aim to stop contractures by reducing people’s exposure to risk factors. As a consequence there would be a vast improvement in quality of life, decrease of the number of reconstructive surgeries required and prevention of unnecessary pain, suffering and disability for burn survivors everywhere.

What's THE treatment?

Although the aim is to prevent burn contractures, both surgical and non-surgical treatments can be used to treat existing contractures. Treatments are also available to prevent contractures.

Physical therapy, occupational therapy and rehabilitation are all focused on preventing and treating contractures. Splinting and positioning can be used to immobilise a joint and stretch the scar. These treatments are often used to keep the joint in an ‘anti-contracture’ position e.g. flexion (bent) is the common contracture for an elbow, therefore the splint, position or exercise is made to extend (straighten) the elbow.  

​​Exercises both passive (by the therapist e.g. stretching) and by the person with a contracture

are important to counteract the pull of the contracture and keep the scar long and supple enough to make full joint movement possible. Scar management techniques to keep the scar soft and pliable such as silicone gels, pressure garments and scar massage can help prevent and treat contractures. Functional activities and encouragement to move and return to tasks is also an important part of rehabilitation. Often pain management is needed in the early stages to encourage effective movement. Burns and scars can be very painful. 

If a contracture has developed, then surgery may be used to ‘release’ the tension in the scar,  which can restore the movement at the joint or feature and improve how the area looks. Once the tension has been released and/or enough scar has been removed from the area local flaps may be used, a skin grafts (with or without artificial dermal templates), or more complex flaps using healthy skin from other areas of the body. In some countries lasers are commonly used to treat contractures by improving the condition and flexibility of the scar.

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Contractures change over time and can get better or worse - it is important for a person at risk of, or with a contracture to be regularly monitored by a doctor or therapist, especially for the first year or two after injury. If the burn occurs as a child, contractures can develop many years after a burn injury because scars don't grow but children do.

HOW CAN THEY BE PREVENTED?

Burns injuries are complicated and to prevent burn contractures, a comprehensive multi-disciplinary team is needed to support the survivor and to address the medical, surgical, physical and psychosocial aspects of the injury. Effective first aid and initial management of the injury, medical and surgical care and long-term physical and psychosocial rehabilitation play an important role in recovery, contracture prevention and overall wellbeing of burn survivors.

We know that contractures occur in the presence of many risk factors, many of these factors are modifiable. Prevention strategies need to involve early interventions for all people with burns injuries to prevent or reduce contracture formation. A clear understanding of the risk factors for burn contractures such as timeliness of treatment, accessibility for patients, education and type of care delivered can reduce the presence and severity of contractures. Different prevention strategies are needed for different situations / environments – especially when planning and implementing effective prevention programmes for high income versus low income countries. 

Dr Contracture believes that by addressing the issues behind the formation of burn contractures and raising awareness, we can achieve a world where burn contractures and the huge suffering that contractures can cause no longer exist. Focus on reducing the occurrence and severity of contractures could drive improvements in burn care healthcare systems all over the world and improve the lives of burn survivors everywhere. To achieve this, we need to bring together a diverse community of people, who can provide a wide range of perspectives and come together to          BURN CONTRACTURES.