Crkvenjas Z., Tymonová J., Adámková M., Kadlcík M., Klosová H., Zámecnfková I.

SUMMARY. Electrical burns are a serious problem within burn medicine even though they are relatively uncommon. The size of the burn is small, but the wound is often deep, and frequently the patient has systemic complications as well. In the majority of patients with such injuries immediate surgical intervention is essential, consisting of escharotomy fasciotomy, and debridement of the devitalized tissues, necrectomy of the burn area. and closure of the defect by a direct suture, a dermo-epidermal graft. or local flap. Our report consists of three case studies.The patients underwent local flap plastic surgery after a full thickness soft tissue loss. All three patients healed primarily and did not require further correction of flaps. Final functional and aesthetic results are very good if the local flap is used appropriately.

Key words: electrical burn, surgical intervention, local flap plastic surgery

INTRODUCTION

  In the years 1997 -2003 at the Burn Center of the FNsP Hospital in Ostrava, 65 patients were hospitalized after electrical burn injuries. 25 patients sustained burn injury from an open fire. 20 patients sustained direct impact at low voltage, and 20 patients sustained impact at high voltage. We heated 28 patients conservatively (mostly those burned by an open fire), while 37 patients required surgical intervention. which consisted of necrectomy of the burned areas and following defect closure by a direct suture, dermo-epidermal graft or local flap plastic surgery. The authors present three case studies from the data file in question. These patients underwent local flap plastic surgery after a full thickness soft tissue loss.

CASE STUDIES

Case study I

A 17-year-old boy sustained injury to the fingers of his right hand after contact with an unprotected conductor (a metal pole used to collect earthworms). The patient sustained burn injury from 220 volts with "no let go" phenomenon, as well as cramps, but no amnesia. The electrocardiogram did not reveal any pathological changes when the patient was monitored on the Intensive Care Unit. The patient burned his right 1 st to 5th forgers with ischemic areas and necrosis above the DIP first and third fingers from the palmar side and the fourth finger dorsally with a flexion contracture of the third finger. We performed necrectomy. Deep structures of the third finger were not involved. The patient sustained subtotal rupture of the flexor tendon, which we sutured. A defect of 1 centimeter square on the fourth finger with exposure of the bone but preserved periosteum was covered by a rotated skin flap on a radial pedicle after fixation of the PIP and DIP joints by Kwires (4). The donor site was sutured primarily (Fig. I ).

After 2 weeks the flap healed, and in the following three weeks the first finger healed as well. We used a direct door flap from the lower abdomen. The third finger healed spontaneously. Only the first finger flap required subsequent correction. The patient has a full mobility in all fingers (Fig. 2).

Case study II

A 49-year-old male who was in contact with electric current 500 volts while working in an electricity substation. The patient was unconscious and brought to us already intubated. He required artificial ventilation. A CT scan revealed fracture of his right frontal sinus and bleeding to the left sphenoid and ethmoid sinuses. The CT scan also revealed mild edema of the frontal cerebral lobe. The patient had a frontal area necrosis of 9x3 cm and another two circular shape necroses of size 15 mm in the parietal area bilaterally. It is likely that these were entry and exit sites. Proximally on the left forearm, the patient had a necrotic strip of 3x1 cm. After stabilization of his overall condition, the patient was extricated; his consciousness stabilized and he did not have signs of a brain injury. Locally we performed debridement. We closed the wound on his left forearm by- a direct suture. Due to the size, shape, and depth of the wound on the patient's head (reaching to the periosteum), we chose to perform local flap surgery. The width of the flap was limited by the space between the individual wounds, so we used a frontopparietal delay flap with a left sided pedicle, which was raised two times (Fig. 3),

and sutured into the defect of a circular shape on the forehead in two weeks. A dermo-epidermal graft covered the donor site. The defect in the right parietal area was closed with a rotation flap. The healing was primary, and the patient was satisfied with the results: he did not wish any correction (Fig. 4).

Case study III

A 60-year-old male sustained electrical current injury of 22,000 volts while repairing a transformer. The patient was briefly unconscious. Brain CT scan did not reveal any pathological changes. The patient sustained 2nd degree burns to his face. neck, buttocks. left thigh. and left shank. At admission the patient had necrotic areas on the vertex of his head, right shoulder. elbow, and in his right groin. The patient also had a 10 cm laceration, which was sutured. The total extent of burn was I8.5°70 of the body surface. We performed early excision of the necrotic areas. We closed the defect on his right elbow by a direct suture. We used a dermo-epidermal graft for areas on the right shoulder and right thigh. The deep wound on the patient's head reached to the periosteum. We used a parietal rotation clap on the right and a transposition flap on the left side. We used dermo-epidermal graft for the donor site (Fig. 5).

The patient healed without any complications. The result was good (Fig. 6).

Neurological complications prolonged his hospitalization. The patient developed a cerebellum syndrome with ataxia and dysbasia. These symptoms began two weeks after injury and gradually spontaneously subsided (3).

CONCLUSION

  All the above mentioned patients healed primarily and were satisfied with the functional as well as aesthetic results. None of the patients wished any further corrections. Even nowadays, when free flap (1) microsurgery is the method of choice- local flap plastic surgery is a very good alternative (2) to direct suture or dermato-epidermal grafts if the defects are deep, such as after electrical burns. Attention to thorough and early debridement of devitalized tissues as well as prevention of infection (2, 5) is fundamental. It is important to plan flap surgery so that the blood supply is adequate. Systemic use of vasodilatation agents is recommended (5). If these conditions are respected, we can expect quick healing with good results.

REFERENCES

1. Benito-Ruiz, J., Baena-Montilla, P., Navarro-Monzonis, A., Bonanad E., Cavadas, P Severe electric burn of the skull. Burns, 20, 1994, p. 553-556.
2. Liu. HY., Zhang, MQ, Wang, RX., Yang, GX., Sun, YD., Liu, QO. Experiences in the treatment of electrical burns covering deep wounds with various tissue flaps. Arta Chir. Plast., 31, 1989, p. 209-225
3. Parashar, A., Chittoria, R., Nanda, V. Extrapyramidal symptoms following electrical burns. Burns, 30, 2004, p. 402-404.
4. Schmoranzova, A. Therapeutic possibilities in soft tissue defects on the dorsum of fingers, Acta Chir. Plast., 37, 1995, p. 52-54.
5. Zhu, ZX., Xu, XG., Li, WP., Wang, DX., Zhang. LY., Chen, LY., Liu, TY. Experience of 14 years of emergency reconstruction of electrical injuries. Burns, 29, 2003, p. 65-72.

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