Functional and clinical outcomes in the Krukenberg amputation

We evaluated the outcomes of the Krukenberg procedure conducted for the loss of a hand secondary to an electrical burn injury in six patients (10 hands). Patient demographics, indications for surgery, surgical strategy, complications, clinical measurements and Disabilities of the Arm, Shoulder and Hand (DASH) score were recorded, in addition to subjective outcome measures, including self-perception of social acceptance and employment status. The median DASH score at follow-up was 22 (range 4-50, interquartile range 25). Patients reported recovery of useful function in operated limbs. We recommend this procedure in low-resource settings when other reconstruction is impossible.Level evidence: IV.

Understanding the safe application of electrosurgery: A cross sectional study of surgeons in KSA

Objectives

To determine whether surgeons at different levels and in different specialties are aware of the safe and acceptable use of electrosurgery. In addition, we aimed to provide a fundamental understanding of electrosurgery and surgical diathermy.

Materials and Methods

A total of 83 doctors from different specialties were randomly selected from several hospitals across KSA. The participants answered a questionnaire featuring 16 questions that addressed 10 domain questions regarding the safe use of electrosurgery.

Results

Analysis revealed that the respondents either lacked knowledge or were unfamiliar with the use and safety of monopolar and bipolar electrosurgery in terms of application. Some respondents were unable to distinguish between the two protocols; this may have resulted in injuries being incurred by patients under their supervision.

Conclusions

Electrosurgery should be formally included in specialty surgical Saudi hospital training programs to increase electrosurgery expertise and surgeons should be re-tested periodically. Our findings may be used to drive future learning. Surgeons may improve their electrosurgery skills by progressing along their learning curve to reach their peak. In addition, surgeons can use virtual reality surgical simulators to practice fundamental and sophisticated electrosurgery skills.

Epidemiology of electrical burns and its impact on quality of life - the developing world scenario

BACKGROUND

Electrical burns are devastating injuries and can cause deep burns with significant morbidity and delayed sequelae. Epidemiological data regarding the etiology, socioeconomic differences and geographic variation are necessary to assess the disease burden and plan an effective preventive strategy. These severe injuries often lead to amputations and thus hamper quality of life in the long term

AIM

To identify the population at maximum risk of sustaining electrical burns. We also studied the impact of electrical burns on these patients in terms of quality of life as well as return to work.

METHODS

The study was conducted at a tertiary referral teaching hospital over a period of eighteen months. All patients with a history of sustaining electrical burns and satisfying the inclusion criteria were included in the study. All relevant epidemiological parameters and treatment details were recorded. The patients were subsequently followed up at 3 mo, 6 mo and 9 mo. The standardized Brief Version of the Burn Specific Health Scale (BSHS-B) was adopted to assess quality of life. Statistical analysis was conducted using IBM SPSS statistics (version 22.0). A P value of < 0.05 was considered statistically significant.

RESULTS

A total of 103 patients were included in the study. The mean age of the patients was 31.83 years (range 18-75 years). A significant majority (91.3%) of patients were male. The mean total body surface area (TBSA) in these patients was 21.1%. In most of the patients (67%), the injury was occupation-related. High voltage injuries were implicated in 72.8% of patients. Among the 75 high voltage burn patients, 31 (41%) required amputation. The mean number of surgeries the patients underwent in hospital was 2.03 (range 1 to 4). The quality of life parameters amongst the patients sustaining high voltage electrical burns were poorer when compared to low voltage injuries at all follow-up intervals across nine domains. In eight of these domains, the difference was statistically significant. Similarly, the scores among the amputees were poorer when compared to non-amputees. The difference was statistically significant in six domains.

CONCLUSION

Electrical burns remain a problem in the developing world. Most injuries are occupation-related. The quality of life in patients with high voltage burns and amputees remains poor. Work resumption was almost impossible for amputees. These patients could not regain pre-injury status. Steps should be taken to create awareness and to implement an effective preventive strategy to safeguard against electrical injuries.

Patterns and outcomes of high-voltage versus low-voltage pediatric electrical injuries: an 8-year retrospective analysis of a tertiary-level burn center

INTRODUCTION

Although electrical injuries (EIs) are rare traumas in the pediatric age group, they are considered one of the most devastating injuries. We aimed to evaluate the patterns and outcomes of pediatric high-voltage (HVI) vs. low-voltage injuries (LVIs), admitted to the burn center within the efforts of determining evidence-based data for contributing to burn prevention strategies.

METHODS

A retrospective study was conducted on children with EIs hospitalized in the Burn Center of Adana City Training and Research Hospital (ACTRH) for eight years (2013-2020). Data including the patients' clinical and demographic characteristics, the percentage of total body surface area with burns (TBSA%), length of hospital stay (LOS), exposure place, electrical current type, and treatment results were collected and analyzed.

RESULTS

EIs were detected in 57 (2.5%) of 2243 acute pediatric burn injury admissions. EIs were most frequently observed in the form of HVIs, among children within the age range of 13-18 years, mostly in residential outdoor environments, where the high-power lines still passing close to the home roofs and balconies, resulting from contact with them. Besides, with a lesser extent in LVIs, in the home environment among children under five years, which was caused by connection with substandard electrical cords/poor-quality electrical devices and inserting an object into the electric sockets. Concerning the mean of TBSA%, HVIs suffered more extensive burns than LVIs. The most frequently affected anatomical regions among HV and LVIs were the upper limb, followed by the lower limb. While superficial partial- and deep partial-thickness burns were significantly more common among the LVIs, full thickness burns were more prevalent among the HVIs. The amputation rate was 12% which only one of them was major amputation (forearm above the elbow joint). HVIs had more elevated CK and CK-MB levels than LVIs but were not correlated with ECG findings. Only one death (caused by HVI) was observed, with a mortality rate of 1.8%.

CONCLUSION

Pediatric EIs are less common than scald or fire-flame related burns in this age group but can cause significant morbidity and even mortality, especially in severe burns. It is possible to prevent possible morbidity and mortality by strengthening compliance with safety precautions, especially with parental education and raising social awareness. In this context, taking necessary precautions for passing high voltage power lines under the ground, the standardization of electrical cables by the relevant legal regulations, the use of socket covers in homes, promoting the widespread use of residual current relays and arrangements to be taken against the use of illegal electricity are among measures for the prevention strategy.

Study of clinical pattern of limb loss in electrical burn injuries

INTRODUCTION

Electrical burn injuries are devastating and cause not only loss of life but also severe disabilities in the form of limb loss. Increase in urbanization, industrialization and overcrowding has led to an increase in electric injuries.

MATERIAL AND METHODS

The study was prospective in nature evaluating electric burns and studied the pattern of limb loss for a duration of 18 months from October 2016 to March 2018. Parameters recorded were demographic data, clinical data regarding the electrical injuries, complications, and outcomes.

RESULTS

Male patients made up 85.3% of cases. Mean TBSA was 24.76 ± 19.18%. Mean age was 27.59 ± 13.73 years. Pediatric patients made up 17%. High voltage burns constituted 68.2 %. Electric contact burn was the most common type making up 49.5% of cases. The most common cause was occupational (38.9%). A fasciotomy was required in 22% of cases with an amputation rate of 38% (209 out of 550). There were 190 major amputations and 106 minor amputations. Overall, the right upper limb amputations were twice as common as the left. The ratio of upper limb: lower limb amputation was 4:1. Fifty patients (23.9%) required revision amputation. The age group 11 to 30 years made up 55.5% of amputations. There was no statistical difference in amputation rates between males (31.31%) and females (41.97%). In patients with TBSA less than 25% amputation rate was 47.77% as compared to patients with more than 25% TBSA, 19.47% (p<0.001). Most amputations occurred due to electric contact burns (74.16%). In the high voltage group, 46.1% underwent amputation vs low voltage group -20.6% (p<0.001). Overall mortality rate was 12.7%. Three hundred patients (55%) had low level of awareness regarding consequences of electric injury. Thirty one percent had medium level of awareness and only 14 % had high level of awareness. There was a significant correlation between education level and awareness in adult patients (p<0.001). Seventy percent of persons with occupational injuries used only footwear and no other protective equipment.

CONCLUSION

Increasing public awareness, safety measures at workplaces are measures that will help reducing electrical burns which reduce limb and life loss.

Lower trapezius myocutaneous flap repairs adjacent deep electrical burn wounds

BACKGROUND

Local tissue damage caused by electrical burns is often deep and severe. High-voltage electrical burns are common in the head, neck and torso areas. These are mostly caused by direct contact with the power supply and are often accompanied by deep injuries of the nerve, blood vessel, muscle, tendon, and bone. We must pay great attention to the clinical treatment of these parts injured by electrical burn.

CASE PRESENTATION

The first case involved a migrant worker who touched a 6-kV high-tension wire when welding steel; this electric shock caused burns in many places. Deep electrical burn wounds were mainly located on the left shoulder and back, characterized by widespread skin and soft tissue defect and bone necrosis. We utilized a lower trapezius myocutaneous flap to repair these wounds in the neck and back caused by deep electrical burns. The flap survived completely and the wound was effectively repaired. The function and shape of the shoulder and back after the restoration were satisfactory. The second case involved a 29-year-old who accidentally touched a high-voltage wire while working and was burned by a 30,000-V electric shock. His wounds were mainly located on the left head, neck, back and left upper limbs. We designed a 30 cm × 12 cm right trapezius myocutaneous flap which completely covered the wound surface; the electrical burn wounds on the neck and back were effectively repaired. After the electrical burn wound was repaired, the neck function returned to normal with a satisfactory shape.

CONCLUSION

The authors report two cases of patients who were burned by high voltage. We used lower trapezius myocutaneous flaps to repair their wounds, which achieved satisfactory clinical results. This study has provided a reliable surgical method for the clinical treatment of deep electrical burn wounds in the neck, shoulders and back.

Epidemiology of electrical burns: a 10-year retrospective analysis of 376 cases at a burn centre in South China

OBJECTIVE

To investigate the epidemiological profile and associated outcomes of electrical injuries at a major burn centre in southern China.

METHODS

This retrospective study enrolled consecutive electrical burn patients admitted to the burn centre of the First Affiliated Hospital of Guangxi Medical University between 2008 and 2017. Demographic and clinical data and outcomes were recorded. Mann-Whitney U tests/Pearson's chi-squared tests were used to examine the differences between low-voltage and high-voltage injuries.

RESULTS

There were 217 high-voltage injuries and 159 low-voltage injuries. High-voltage burns were frequently observed between March and August, and low-voltage burns peaked between June and September. Burn patients were mainly men. Most burns occurred in participants aged 21 to 50 years and in industrial workers and electricians at work or householders at home. Only one person with high-voltage burns died (a mortality rate of 0.46%). Amputation rates were 37.33% for high-voltage burns and 22.01% for low-voltage burns. High-voltage injuries were associated with more extensive burns, longer hospital stays, and more complications and amputations.

CONCLUSIONS

More attention should be paid to prevention of electrical burns in male adults. Particular focus is needed on industrial workers, incidents in the spring and summer, and high-voltage injuries.

Epidemiological analysis of pediatric burns in the Dominican Republic reveals a demographic profile at significant risk for electrical burns

OBJECTIVE

Pediatric burns are preventable with legislative and infrastructural changes. Although retrospective audits of many low- and middle-income countries have aided preventative efforts, the epidemiological status of burns in the Caribbean is not known. This study characterizes pediatric burns in the Dominican Republic (DR) and compares these to age-matched North American records captured by the National Burn Repository.

METHODS

A retrospective audit of 1600 patients admitted to the Unidad de Niños Quemados Dra. Thelma Rosario Hospital, the island's only major pediatric burn center, between January 2010 to March 2017 was performed. Epidemiological variables analyzed included age, gender, burn mechanism, year, month, city, admission duration, nationality, mortality, and %TBSA.

RESULTS

Pediatric burn patients in the DR sustained larger burns (8.2% vs. 6.5% TBSA) and spent more days in the hospital (10 vs. 6 days). Females were overrepresented (M:F=1:1.5) and mortality amongst admitted patients was 4-fold higher (2.8% vs. 0.7%). Electrical burns were significantly overrepresented in DR (21%) compared to age-matched North American patients (2%). Although electrical burns were smaller (4% TBSA), compared to scald (14% TBSA), and flame (19% TBSA), these burns preferred hands and had a high mortality rate (3%). No significant seasonality in burn mechanisms were observed. Finally, we report geographical and age group differences in the distribution of burn mechanisms and highlight particularly vulnerable subpopulations.

CONCLUSION

This investigation identifies a demographical profile where electrical burns account for a significant percentage of the burn population. This provides a basis for concentrating preventative efforts in vulnerable populations.

High-voltage electrical injury complicated by compartment syndrome and acute kidney injury with successful limb salvage: A case report and review of the literature

INTRODUCTION

Although an uncommon form of admission to a burns centre, the deep, penetrating nature of noxious currents mean that electrical burns have the most catastrophic consequences of all burn injuries. Understanding the physics of electricity is crucial to explaining the mechanisms of tissue damage and organ failure in electrical injuries which necessitate special management above and beyond that of regular thermal burns.

PRESENTATION OF CASE

We present a young man who suffered significant occupation-related electrical burns that was complicated by compartment syndrome, rhabdomyolysis and acute kidney injury. He required multiple surgeries (including fasciotomy as well as soft tissue reconstruction), critical care and lengthy rehabilitation.

DISCUSSION

Rhabdomyolysis is common sequela of electrical burns and may result in severe and permanent metabolic and renal impairment. High cut-off dialysis membranes have shown great promise in myoglobin removal but further studies are required to determine whether this improves clinical outcomes. Debridement and decompression are the cornerstones of initial surgical intervention and are crucial to minimising infectious complications and preserving vital structures. Free tissue transfer has become increasingly popular, but the ideal timing of microsurgery is still uncertain. Nonetheless, pedicled flaps remain widely used and still have an important role in reconstruction of electrical burns.

CONCLUSION

Patients with electrical injuries have several unique acute manifestations that differ from other burns. Prognosticating outcomes is difficult, as the full scale of damage is seldom immediately evident. Multiple organ systems are often affected, which makes the treatment of such patients exceptionally challenging, multi-disciplinary and resource-intensive.

Early debridement and delayed primary vascularized cover in forearm electrical burns: A prospective study

AIM

To look into the management options of early debridement of the wound, followed by vascularized cover to bring in fresh blood supply to remaining tissue in electrical burns.

METHODS

A total of 16 consecutive patients sustaining full thickness forearm burns over a period of one year were included in the study group. Debridement was undertaken within 48 h in 13 patients. Three patients were taken for debridement after 48 h. Debridement was repeated within 2-4 d after daily wound assessment and need for further debridement.

RESULTS

On an average two debridements (range 1-4) was required in our patients for the wound to be ready for definitive cover. Interval between each debridement ranged from 2-18 d. Fourteen patients were provided vascularized cover after final debridement (6 free flaps, 8 pedicled flaps). Functional assessment of gross hand function done at 6 wk, 2 mo, 3 mo and 6 mo follow-up.

CONCLUSION

High-tension electrical burns lead to significant morbidity. These injuries are best managed by early decompression followed by multiple serial debridements. The ideal timing of free flap coverage needs further investigation.

[Principles of plastic pediatric surgery: Thirty years of surgical practice]

In this document, Pr Guy Magalon presents a reflection on the plastic pediatric surgery drawn from 30 years of surgical practice. His thinking is supported by several examples of plastic surgery results from children reviewed in adulthood. These cases highlight the evolution of surgical practices and the need for continuing education for surgeons to adapt to technical progress. Professor Magalon honors his masters and shares his personal vision of the principles of pediatric plastic surgery.

Effect and possible mechanism of monocyte-derived VEGF on monocyte-endothelial cellular adhesion after electrical burns

OBJECTIVE

One of the major obstacles in the treatment of severe electrical burns is properly handling the resulting uncontrolled inflammation. Such inflammation often causes secondary injury and necrosis, thus complicating patient outcomes. Vascular endothelial grow factor (VEGF) has emerged as an important mediator for the recruitment of monocytes to the site inflammation. This study was designed to explore the effects and possible mechanism of VEGF on monocyte-endothelial cellular adhesion. To do so, we used a cultured human monocytic cell line (THP-1) that was stimulated with serum derived from rats that had received electrical burns.

METHODS

Serum was obtained from rats that had received electrical burns. Both the VEGF and soluble flt-1 (sflt-1) concentrations of the serum were determined by double-antibody sandwich ELISA. The concentrations of VEGF, sflt-1, and TNF-α obtained from the cell-free cultured supernatant of THP-1 cells that had been exposed to the serum were then determined by double-antibody sandwich ELISA. Serum-stimulated THP-1 cells were added to wells with a monolayer of endothelial cells to detect the level of monocyte-endothelial cells adhesion. Finally, the state of phosphorylation of AKT was determined by Western blotting.

RESULTS

Both in vivo and in vitro studies showed that compared to controls, the levels of VEGF were significantly increased after electrical burns. This increased was accompanied by a reduction of sflt-1 levels. Furthermore, the serum of rats that had received electrical burns was able to both activate monocytes to secrete TNF-α and enhance monocyte-endothelial cell adhesion. Treatment with the serum also resulted in an up-regulation of the phosphorylation of AKT, but had no effect on the total levels of AKT. Phosphatidylinositide 3-kinases (PI3K) inhibition decreased the number of THP-1 cells that were adhered to endothelial cells. Finally, sequestering VEGF with sflt-1 was able to reduce the effect on monocyte-endothelial cells adhesion by blocking the PI3K signaling pathway.

CONCLUSION

Our results indicate that VEGF is implicated in the pathogenesis of inflammation after electrical burns. Inhibition of VEGF activity could attenuate monocyte-endothelial cells adhesion by suppressing the state of phosphorylation of AKT, which is downstream of the PI3K signaling pathway.

Electrical burns in sports fishing: a case report

Electrical burns are among the most devastating types of burns, with wide-ranging injuries. They can sometimes occur in the context of fishing, usually involving high voltages. The authors present the case of a 59-year-old-man who suffered a sports accident during a fishing competition, with the formation of an electrical arc due to proximity of the fishing rod and high voltage cables. He presented burns affecting 3% of TBSA, third degree deep burns on trunk and left hand; no signs of cardiac injury. He was admitted to our Burn Unit for monitoring, care dressing and surgical treatment; complete wound healing was achieved after 24 days. Due to its relatively small share among burns, published data on electrical injuries and fishing remain scarce, and differ in patient collectives due to infrastructural or environmental differences. The authors are not aware of published specific reports on electrical burns in sports fishing practice, like the case here presented. The authors want to alert for potential medical, social and economic consequences of this type of sports accidents that could be entirely avoidable with some preventive measures.

A challenging case of total phalloplasty

Plastic surgery continues to maintain a prominent presence in the evolution of male genital reconstruction. In this case report, we are presenting a case of post-electric burn with a total loss of penis. Sustaining other major injuries following an electric burn with loss of right upper limb and extensive tissue damage to left upper limb, abdomen and both thighs, this young male patient was initially managed from life-threatening problems. With many options closed following a major electric burn and its acute management, penile and urethral reconstruction was a unique and a great challenge in this patient. Heeding to the patient's wish of male pattern micturition, we had performed a successful reconstruction of urethra and entire phallus with groin flap.