MR imaging findings of high-voltage electrical burns in the upper extremities: correlation with angiographic findings

Extended Paraumbilical Perforator Flap Pedicled With the Inferior Epigastric Artery for Coverage of Type III Circumferential Electrical Burns of the Wrist

Type III electrical burns on the wrist are characterized by circumferential wounds, three dimensional with sandwich-like necrosis, and progressive blood circulation disturbances. Limb salvage is challenging, and success in meeting this challenge depends on vascular reconstruction and wound coverage. This article is intended for the following purposes: to investigate the principles of wound debridement, the management of involved blood vessels, and the clinical effects of the extended paraumbilical perforator flap pedicled with the inferior epigastric artery for coverage of type III circumferential electrical burns of the wrist. A total of 13 male patients (age, 20 to 43 years; average, 29 years) were enrolled in the study. After early escharotomy, debridement, and vascular reconstruction, all wounds were repaired with the extended paraumbilical perforator flap pedicled with the inferior epigastric artery. Flap survival was achieved in all 13 patients. Subcutaneous liquefaction necrosis and infection beneath the flap occurred in three patients. Radial or ulnar artery reconstruction via the great saphenous vein (GSV) graft was performed in 12 cases. All patients had a mean follow-up of 6 to 36 months, and the flaps demonstrated satisfactory flexibility and texture. Hand function was preserved in eight patients, and no patients developed abdominal hernia. Thorough debridement, early vascular reestablishment, and wound coverage are essential for the overall limb salvage effort for type III circumferential electrical burns of the wrist. The extended paraumbilical perforator flap may provide a new and appropriate option for the primary repair of extensive soft tissue defects.

Reconstructive Management of Devastating Electrical Injuries to the Face

BACKGROUND

Devastating fourth-degree electrical injuries to the face and head pose significant reconstructive challenges. To date, there have been few peer-reviewed articles in the literature that describe those reconstructive challenges. The authors present the largest case series to date that describes the management of these injuries, including the incorporation of face transplantation.

METHODS

A retrospective case series was conducted of patients with devastating electrical injuries to the face who were managed at two level-1 trauma centers between 2007 and 2011. Data describing patient injuries, initial management, and reconstructive procedures were collected.

RESULTS

Five patients with devastating electrical injuries to the face were reviewed. After initial stabilization and treatment of life-threatening injuries, all five underwent burn excision and microsurgical reconstruction using distant flaps. Two of the patients eventually underwent face transplantation. The authors describe differences in management between the two trauma centers, one of which had the availability for composite tissue allotransplantation; the other did not. Also described is how initial attempts at traditional reconstruction affected the eventual face transplantation.

CONCLUSIONS

The care of patients with complex electrical burns must be conducted in a multidisciplinary fashion. As with all other trauma, the initial priority should be management of the airway, breathing, and circulation. Additional considerations include cardiac arrhythmias and renal impairment attributable to myoglobinuria. Before embarking on aggressive reconstruction attempts, it is advisable to determine early whether the patient is a candidate for face transplantation in order to avoid antigen sensitization, loss of a reconstructive "lifeboat," surgical plane disruption, and sacrifice of potential recipient vessels.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Arterial injuries in extremities trauma, angiographic findings

At present, trauma is a common problem and regarded as the third cause of mortality in different societies. Significant part of injuries resulting from trauma is due to vascular damages. Tissue ischemia associated with vascular injuries is regarded as medical emergencies which can result in irretrievable ischemia if it continues for 6 h. Therefore, early diagnosis and quick treatment of vascular injuries are of high importance. In this cross sectional study, all trauma patients referred with possible vascular injury to angiography department of Tabriz Imam Khomeini Hospital from Apr. 2011 to Apr., 2012 underwent angiography. The results were compared with the similar studies conducted in other countries. Out of all patients, angiography detected vascular injury in 75 cases consisting of 93.7% of men and 5.3% of women. Motor vehicle (93.3%) especially motorcycles accidents were the most common cause of the damages. Leg was the most common site of trauma (62.2%) and associated fracture was seen in 86.7% of cases. Also, double fracture of leg was the most common associated fracture. Anterior tibial artery (36%) and complete arterial occlusion (62.7%) were the most common injured vessel and vascular injury, respectively. Vascular injuries are more common in young men (20-30 years old) mainly resulted from blunt trauma associated with motor vehicle especially motorcycle accidents. Leg and anterior tibial artery were introduced as the most common site and injured artery, respectively.

Magnetic resonance imaging features of soft tissue and vascular injuries after high-voltage electrical burns and their clinical application

OBJECTIVE

To study the clinical application of MRI (magnetic resonance imaging) and MRA (MR angiography) technologies for examining the imaging characteristics of muscular and vascular injuries following high-voltage electrical burns.

METHODS

MRI and MRA examinations were conducted on 18 upper limbs and 8 lower limbs of 18 patients with high-voltage electric burns. Exploratory operations were performed on the necrotic muscle and injured vessels that had abnormal MRI and MRA signals. The necrotic muscle and embolised vessels were removed, and the muscle viability was tested. Meanwhile, histological examinations of the necrotic muscle and injured vessels were performed.

RESULTS

Abnormal signals from the MRI were observed from the 18 upper limbs and 8 lower limbs of these patients. Two kinds of T1-weighted image signals were observed in the necrotic muscle. One form of signal enhancement indicated that the muscular tissue was necrotic, whereby a distinct demarcation was observed between necrotic and normal tissues. The other result was characterised by no signal enhancement in the area of the vessel where blood flow was entirely occluded and the muscle was entirely necrotic. The signal of the T2-weighted image was significantly enhanced in edematous and necrotic muscles and was higher than that of the T1-weighted image. However, the enhancement of the T2-weighted signal exhibited an uneven floccus appearance and had no distinct boundary. MRA of the 18 upper limbs and 8 lower limbs were abnormal and the main pathological manifestations included circuitous arteries and thromboses. The necrotic muscle and injured vessels that were found by MRI and MRA were removed upon exploratory surgery.

CONCLUSIONS

Specific MRI and MRA imaging characteristics can be observed in muscular and vascular injures following high-voltage electrical burns. MRI and MRA were very useful for assessing the scope and degree of injury following high-voltage electrical burns, which was helpful to guide the explorative surgery.

The role of preoperative radiological assessment of vascular injury on surgical decision making in mutilating injuries of the upper extremity

Preoperative assessment of the extent of vascular injury is important in patients with mutilating injuries of the upper extremity. The aim of this report was to discuss the influence of computed tomography angiography (CTA) and digital subtraction angiography (DSA) on the operating room decision-making in mutilating injuries and limb-salvage procedures of the traumatic upper extremity. Four DSA and 3 CTA were performed in 7 patients with a mean age of 28.3 (range, 4-48) years. The results of the DSA and CTA altered the preoperative planning. In 5 patients, the reconstructive decision of the type of flap was altered, whereas in all 7 patients, either the level or type of anastomosis was changed after radiologic investigations. The mean follow-up period was 37.8 months. During the follow-up period, all patients underwent subsequent procedures such as sensory restoration, tendon reconstruction, or capsulotomy. The effects of radiologic results in which flap selection, target donor vessel, and level and type of anastomosis have changed are discussed in correlation with intraoperative findings.