• Users Online: 3130
  • Print this page
  • Email this page

 
Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 11  |  Issue : 3  |  Page : 131-137

Management of wrist electrical burns with utilisation of recent modalities for better functional outcome: An institutional approach


1 Department of Plastic Surgery and Burns, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
2 St. Johns Medical College, Bengaluru, Karnataka, India
3 Apollo Hospital, Chennai, Tamil Nadu, India
4 Department of Computer Science, St. Thomas College (Autonomous), Thrissur, Kerala, India

Date of Submission05-Jan-2022
Date of Decision11-Feb-2022
Date of Acceptance11-Feb-2022
Date of Web Publication08-Jun-2022

Correspondence Address:
Pradeoth Mukundan Korambayil
Professor, Villa No. 2, Confident Aries, Opp. Ganam Movies, Valarkavu, Kuriachira PO, Thrissur 680 006, Kerala
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcsr.jcsr_3_22

Rights and Permissions
  Abstract 


Background: The aim is to study the sequence of events contributing the survival of wrist electrical burns and reconstructive options for salvage of soft tissue of electrical burns of wrist.
Methods: Data of patients with high tension electrical burns involving the wrist admitted in our hospital from January 2018 to December 2020. There were 17 patients with electrical burns with wrist injury. Patients from age 18 to 65 years were included in the study. Patients were subjected to bio immunoassay, infrared thermography, indocyanine fluorescent scan, hyperbaric oxygen therapy and reconstructive procedures.
Results: Among 17 patients, 16 were male. Their age ranged from 20 to 61 years. The injury resulted from 11 kv voltage line most often and the patients were admitted within a day of injury. All patients were subjected to multiple staged procedures of debridement and reconstruction. 7 patients were subjected to amputation of the limb, 5 patients subjected to reconstruction in terms of abdominal flap and 4 with groin flap and one perforator plus flap was used to cover the wrist defect.
Conclusions: Wrist electrical burns due to its crucial location, requires knowledge on disease process, if ignored will directly lead to significant morbidity. Utilisation of newer modalities will help in timely intervention and salvage of the limb.

Keywords: Bio-impedance assay, electrical wrist burns, hyperbaric oxygen therapy, indocyanine fluorescent assay, infrared thermography


How to cite this article:
Korambayil PM, Thattaruparambil VP, Dilliraj VK, Varkey PA, Ravindran K R. Management of wrist electrical burns with utilisation of recent modalities for better functional outcome: An institutional approach. J Clin Sci Res 2022;11:131-7

How to cite this URL:
Korambayil PM, Thattaruparambil VP, Dilliraj VK, Varkey PA, Ravindran K R. Management of wrist electrical burns with utilisation of recent modalities for better functional outcome: An institutional approach. J Clin Sci Res [serial online] 2022 [cited 2022 Aug 12];11:131-7. Available from: https://www.jcsr.co.in/text.asp?2022/11/3/131/347038




  Introduction Top


Burns injuries are serious emergency health concern all over the world. Electricity being the most indispensable source of energy, its growth in Indian sector results in frequent risks of accidents. The morbidity and mortality caused by high tension electricity are more common in Indian practice due to the lack of proper preventive measure. Severe functional disabilities, amputations and prolonged hospitalisation are required for electrical burns. Most of these injuries usually involve the hand and wrist as entry point and exit point of electricity. Wrist being the bottleneck region of the upper extremity, the involvement of wrist requires high-end vigilance from the burn surgeon's perspective for limb salvage. High tension electric burns of wrist often result in damage of tendon, peripheral nerves, vascular structures, bones resulting in high functional disability and amputation rates.[1] A sequence of events including systemic changes affects the vulnerability of upper extremity electrical burns. More crucial segment affected in the upper extremity is the wrist. In our study, our effort is to address the sequence of events for increasing the survival of the wrist in upper extremity electrical burns and available reconstructive options for the salvage of soft tissue of electrical burns of wrist.


  Material and Methods Top


Our study is retrospective in nature where we analyzed the data of patients with high tension electrical burns involving the wrist admitted in our hospital from January 2018 to December 2020. The study was cleared by ethics committee. There were 17 patients with electrical burns with wrist injury. Patients from age 18 to 65 years were included in the study. Patients with pre-existing cardiac or renal diseases or history of fasciotomy or any other hand reconstruction surgeries were excluded from the study. Patients with heart disease with pacemaker, pregnancy, history of alcohol or drug abuse were also excluded. All patients on admission underwent primary survey followed by a thorough secondary survey for associated injuries. Patients are admitted in ICU for cardiac evaluation, neurological evaluation, respiratory, abdominal problems, renal injury (myoglobinuria, acute tubular necrosis), musculoskeletal injury (muscle necrosis, compartment syndrome, rhabdomyolysis, fracture), psychological evaluation done.

Before fluid resuscitation is started, a primary assessment with bio-impedance assay (BIA) was done to assess the initial calculation of total body volume to extra and intracellular volume with body stat. Initially, 100 ml/h Ringer lactate is supplemented and then slowly brought down to 50 ml/h and titrated according to the renal output. These patients were started with hyperbaric oxygen therapy to supplement the oxygen demand to preserve the marginal tissue. Skin perfusion was measured with transcutaneous oximetry (TCOM) probe to access the tissue level oxygenation of injured limb. An initial assessment with TCOM will act as a guide to detect the deterioration of limb perfusion at tissue level during the natural course of the disease or after subsequent debridement.

In case of overt compartment syndrome, fasciotomy was performed. Wound is examined clinically and with infrared thermography thereafter sequentially whenever dressing is done to assess the depth of the wound. If renal parameter is adequate, then these patient's wounds are also subjected to evaluation to know the perfusion of the wound with fluorescein dye. Assessment from clinical, infrared and indocyanine green perfusion directs treatment in terms of reconstruction or amputation of the limb.

In case of intervention, surgery was performed always in stages, as demarcation of necrotic tissue may vary from 3 to 6 weeks and so most of the reconstruction efforts for electrical burns of the wrist were started after 3–4 weeks when the tissue perfusion is understood completely. Administration of hyperbaric oxygen therapy is continued as it helps in reserving the marginal surviving tissues. Hyperbaric oxygen is discontinued and started again when reconstructive procedure was initiated.


  Results Top


Among 17 patients 16 were male. Their age ranged from 20 to 61 years. The injury voltage mostly 11 kv line and the patients were admitted within 1 day of injury (Table 1). All patients were subjected to multiple staged procedures of debridement and reconstruction. 7 patients were subjected to amputation of the limb, 5 patients subjected to reconstruction in terms of abdominal flap and 4 with groin flap and one perforator plus flap was used to cover the wrist defect. Hyperbaric oxygen therapy helped in the diffusion of oxygen to marginal tissue which survives through the collateral capillary network. Identification of molecular pathology and utilisation of technology in crucial areas like wrist electrical burns will certainly increase the quality of burns management [Figure 1].{Figure 1}

Cases

Case 1

A 23-year-old male working on electrical post-sustained high voltage electrical injury involving the wrist and the distal forearm. The patient was treated with repeated debridement till the demarcation of healthy tissue [Figure 2]. After proper planning, abdominal flap from ipsilateral side was harvested to cover the near circumferential soft-tissue defect of wrist and forearm. Donor area was partially closed and remaining area was graft with skin graft harvested from the left thigh. Defect on the left ring finger volar aspect was grafted. After 3 weeks, flap division was performed. Flap perfusion was adequate and the post-operative periods were uneventful flap [Figure 3]. Thirty-two sessions of hyperbaric oxygen therapy were administered during the stay in hospital.{Figure 2}{Figure 3}

Case 2

A 27-year-old male, during work, sustained electrical burns involving the right wrist region [Figure 4]. The patient was managed conservatively after initial resuscitation following which the wound was assessed according to the departmental protocol. After demarcation of tissue necrosis, the patient was taken the operation theatre and the wound was reassessed following debridement. There was segmental necrosis of Flexor digitorum superficial of the index and the middle finger, segmental avascular median nerve. Palmaris longus tendon was utilised for the reconstruction of flexor tendon of index and middle finger. Median nerve was reconstructed with the contralateral sural nerve cable graft [Figure 3]b. Soft tissue defect on the wrist was reconstructed with ipsilateral groin flap cover. Donor area closed primarily. After 3 weeks, the groin flap was divided and flap inset completed [Figure 5]. About 24 sessions of hyperbaric oxygen therapy were administered during the hospital stay of patient. Flap thinning was performed after 3 months of flap inset [Figure 6]. Post-operative periods were uneventful.{Figure 4}{Figure 5}{Figure 6}

Case 3

A 61-year-old male while attempting to pluck jackfruit from the tree with an iron rod was stuck to high voltage electric current following which he developed electrical burns to the right wrist in a circumferential manner. The patient developed compartment syndrome of the hand following which fasciotomy was performed. Sequential debridement was done [Figure 7]. Later, he developed pre-gangrenous changes and venous congestion of the region distal to wrist following which amputation of the limb was performed at appropriate level [Figure 8]. Hyperbaric oxygen therapy was administered up to 18 sessions.{Figure 7}{Figure 8}



Progress of necrotic process in electrical burns affecting nearby perforators and HBO for marginal tissue survival is shown in [Figure 9].{Figure 9}


  Discussion Top


Electric burn injury is one of the most destructive injuries seen in an emergency room. Electrical injury has a potential of causing significant functional disability and extensive disfigurement. The intensity of the electric burn depends on the voltage, current flow and resistance offered by the tissue. Local generation of heat and direct passage of current through the tissues may cause significant damage to injured site. Coagulative necrosis of the cells and disruption of cell membrane leads to cell death and tissue loss in electrical burns. Most of these injuries involve the hand and wrist as entry point and exit point of electricity. Wrist as the bottleneck region of the upper extremity, the involvement of wrist requires high-end vigilance from the burn surgeon's perspective for limb salvage. Every change in parameters due to injury and the measures taken to resolve from the injury will significantly affect the prognosis of salvage of wrist region. Necrosis of the wrist skin potentially exposes the tendons, nerves, vessels and bone which may directly increase the morbidity resulting in higher incidence of amputation.

In view to prevent acute renal failure due to myoglobinuria, these patients are hydrated well till adequate urinary output is established. There is always a possibility of stagnation of fluids in the extracellular and intracellular compartment due to excessive fluid administration. The use of bio-electrical impedance analysis (BIA) as a guide for fluid management, during resuscitation and de-resuscitation will certainly help a burns surgeon to effectively tide over the crisis of initial management of electrical burns. There is always a higher incidence of compartment syndrome in the affected limb which affects survival of soft tissue of the wrist. BIA can measure the total body water (TBW) and extracellular body water (EBW) from which the intracellular body water (IBW) could be calculated. Sequential measurement of BIA from a patient of electrical burns will provide a trend of TBW, EBW and intracellular volume. Expansion of ECW and loss of ICW are typical features of systemic illness, arising from the loss of protein into extracellular space due to cell disintegration which is more common in electrical burns. Moreover, the compartmental BIA measurement of the involved and uninvolved limb could provide us with parameters of deterioration of the cell status due to injury in particular limb. BIA measures whole body or regional or segmental impedance, phase angle, resistance, reactance and capacitance, by means of an electric current transmitted at frequencies of 200 and 5 Hz.[2],[3] The property of whole-body bioimpedance is much more sensitive to volume changes in the limbs than in the trunk which could be very well utilised for the electrical burns involving the upper limb.[4]

Controlled fluid administration can reduce the progression of initial tissue damage, but it cannot control the acute process such as inflammation, tissue oedema, compartment syndrome and tissue necrosis. Extremities are more prone to manifesting tissue oedema, compartment syndrome and tissue necrosis as the intermuscular fascial septa limits the tissue space, which in turn impairs circulation to the affected region. Inflammatory process when left uncontrolled may result in tissue necrosis. There is always difficulty to decide whether an involved extremity is inflamed or infected and this may lead to unnecessary medical interventions. At the zone of injury, tissues may be non-viable with irreversible damage which may not respond to intervention. The next zone outward consists of variably injured tissues that may recover if the process of inflammation is controlled. Most of our therapeutic manoeuvers are focused on this penumbra of marginal tissue in an attempt to maximise recovery of the tissue with doubtful viability. Finally, the third outer zone of minimally injured tissues may be at risk from the processes of secondary injury resulting from delayed, physiologic inflammatory responses to electrical burn injury.

Sometimes the quantity of tissue loss and destruction caused by secondary injury can be more than the actual loss from the primary event that had occurred due to electrical burns. Hence, there is a need for interventions which impede the progress of inflammation, preserve marginal tissue under risk, prevention of ischaemia and hypoxic advancement of the injured tissue. Measurement of compartment pressure of the involved limb before consideration of fasciotomy is always recommended. Only when there is an increase of compartmental pressure up to 30–45 mmHg, it becomes an absolute indication for fasciotomy.[5],[6] Measurement of compartmental pressure is not always feasible in many medical centres in India, and the diagnosis of compartment syndrome is still based on clinical standards. Early fasciotomy in the treatment of electric burn injury is done to avoid the consequence of compartment syndrome. However, early fasciotomy is not without complication. It may result in disfiguring scars, contractures, nerve damage and significantly lengthening the course of treatment.[7] In early compartment syndrome, Hyperbaric oxygen (HBO) therapy may reduce the penumbra of cells at risk for delayed necrosis and secondary ischaemia.[8] HBO therapy is included in the treatment regimen of electrical burns injury either as an adjunct for surgical intervention or as a primary tool in the treatment of compartment syndrome or cellulitis.[9] Breathing of 100% oxygen under increased ambient pressure shows prevention of reperfusion injury, reduction of tissue oedema and reversal of sub-lethal tissue damage.[8],[9] The effect of HBO therapy on the local reaction in electrical burns' victims exceeded the one usually seen when treating a trauma-induced inflammation and compartment syndrome as true bacterial cellulitis manifests after the formation of tissue necrosis and infection in these cases.[10]

In our series, after the initial stabilisation, HBO therapy sessions were initiated. Six sessions of HBO therapy sessions were administered, each session extending for 90 min with pressure ranging from 1.8 to 2.4 ATA.[9] The sessions were extended according to the clinical progress of the disease. The same regimen was followed in case of compartment syndrome. The sessions were extended in chronic wound.[9] In our sessions of therapy, we did not experience any complications related to hyperbaric oxygenation. According to our experience, hyperbaric oxygenation is helpful in the management of impending compartment syndrome which may require a fasciotomy later. It is difficult to explain if the patients were not treated with HBO, the local reaction would have progressed to compartment syndrome or tissue necrosis. However, in the hands of expertise team treating electric burns injuries, HBO therapy seems to be an effective tool when the patient's clinical condition is in-between conservative management and definitive surgical intervention. Compartmental fluid accumulation could also be measured by the BIA which along with clinical assessment could be useful for the assessment for compartmental release.

Considering the decreased rates of adverse effects of HBO therapy and its usefulness in clinical situations, it could be justified that the empiric use of HBO therapy may be considered in electric burns cases to prevent overt manifestation of compartment syndrome and prevent deterioration of marginal viable tissue. In our observation, due to early recovery of superficial injury due to HBO, there is always an early demarcation of surviving and necrotic tissues which helps in surgical decision making in burns injury.[11] HBO therapy after surgical debridement, soft tissue cover is beneficial in terms of reducing oedema of the inflamed operated site. Hence, we prefer HBO therapy at least six sessions in those patients who underwent surgery. Further investigations about the usefulness of HBO therapy for such clinical condition might be warranted.

TCOM used to measure tissue oxygenation in hyperbaric oxygen therapy is yet another significant tool to understand the tissue perfusion of the extremities in the electrical burn injury. Repetitive measurements during the treatment course may help to follow the healing process. TCOM may be used in electrical burns for prediction of healing, success of surgical procedure, prediction of severity of symptoms or disease, prediction of success of vascular reconstruction prediction of the level of amputation. Digital measurement of TCOM is yet advancement in understanding tissue perfusion with more accurate data.

Infrared thermography helps in understanding the surface temperature of the injured tissue, and indocyanine green fluorescent assay will provide us regarding the capillary perfusion of the tissue.[12] With simultaneous usage of both investigations along with clinical assessment, a predictable conclusion could be drawn to understand the intensity of injury in electrical burns, particularly in the sensitive areas like wrist region.

As electric current passes through the least resistant regions of the body, particularly travelling through the neurovascular bundles. Soft-tissue reconstruction of the electrical burns defects poses with problems of lack of proper delineation of vascularity. Complications associated with the flaps are common when the flaps are harvested in and around the zone of injury. Moderate-to-large defects due to electrical burns of the hand and forearm are addressed commonly by groin or abdominal flaps as this flap vascularity is away from the zones of injury. Reconstruction with free tissue transfer becomes difficult as these injuries cause significant disruption of Virchow's triad by compartment syndrome and vascular destruction [both arterial and venous]. In our series, most of the reconstruction of wrist was with pedicle groin or abdominal flap. For small defects, a groin or abdominal flap may cause more morbidity than the regional or local flaps. Smaller soft-tissue reconstruction with local or regional flaps for electrical burn injury may require proper planning to achieve adequate coverage. One small to medium-sized defect in the wrist was addressed by perforator plus flap. Amputation of the limb was also considered when the options of reconstruction were depleted. Usage of effective prosthesis should also be considered when line of treatment leads us to amputation.

Complex factors involve in the evolution and the treatment process of electrical burn injury. With advanced technologies, various tools are helpful in the management of complicated electrical burn injury.

Wrist electrical burns due to its crucial location, requires knowledge on disease process, if ignored will directly lead to significant morbidity. Routine reconstructive ladder could not be applied as there is significant vascular disruption due to the transmit of electric current through neurovascular structures. Utilisation of newer modalities will help in timely intervention and salvage of the limb.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wang C, Shen YM, Qin FJ, Hu XH. Free flow-through anterolateral thigh flaps for wrist high-tension electrical burns: A retrospective case series. Biomed Environ Sci 2020;33:510-7.  Back to cited text no. 1
    
2.
Rombeau JL, Bandini L, Barr R, Bier DM, Bistrian BR, Blair SN, et al. Bioelectrical impedance analysis in body composition measurement. NIH Technol Assess Statement 1994;12-14:1-35.  Back to cited text no. 2
    
3.
Plank LD, Monk DN, Gupta R, Franch-Arcas G, Pang J, Hill GL. Body com- position studies in intensive care patients: Comparison of methods of measuring total body water. Asia Pac J Clin Nutr 1995;4:125-8.  Back to cited text no. 3
    
4.
Medrano G, Eitner F, Floege J, Leonhardt S. A novel bioimpedance technique to monitor fluid volume state during hemodialysis treatment. ASAIO J 2010;56:215-20.  Back to cited text no. 4
    
5.
Garfin SR, Castilonia RR, Mubarak SJ, Hargens AR, Russell FE, Akeson WH. Rattlesnake bites and surgical decompression: Results using a laboratory model. Toxicon 1984;22:177-82.  Back to cited text no. 5
    
6.
Schexnayder SM, Schexnayder RE. Bites, stings, and other painful things. Pediatr Ann 2000;29:354-8.  Back to cited text no. 6
    
7.
Gold BS, Barish RA, Dart RC, Silverman RP, Bochicchio GV. Resolution of compartment syndrome after rattlesnake envenomation utilizing non-invasive measures. J Emerg Med 2003;24:285-8.  Back to cited text no. 7
    
8.
Rainer PP, Kaufmann P, Smolle-Juettner FM, Krejs GJ. Case report: Hyperbaric oxygen in the treatment of puff adder (Bitis arietans) bite. Undersea Hyperb Med 2010;37:395-8.  Back to cited text no. 8
    
9.
Bhutani S, Vishwanath G. Hyperbaric oxygen and wound healing. Indian J Plast Surg 2012;45:316-24.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Korambayil PM, Ambookan PV, Abraham SV, Ambalakat A. A multidisciplinary approach with hyperbaric oxygen therapy improve outcome in snake bite injuries. Toxicol Int 2015;22:104-9.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Korambayil PM, Ambookan PV, Karangath RR. Role of infrared thermography in the assessment of burn wounds treated with and without hyperbaric oxygen therapy. Indian J Burns 2019;27:78.  Back to cited text no. 11
  [Full text]  
12.
Sen CK, Ghatak S, Gnyawali SC, Roy S, Gordillo GM. Cutaneous imaging technologies in acute burn and chronic wound care. Plast Reconstr Surg 2016;138:119S-28S.  Back to cited text no. 12
    




 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Material and Methods
Results
Discussion
References

 Article Access Statistics
    Viewed428    
    Printed10    
    Emailed0    
    PDF Downloaded60    
    Comments [Add]    

Recommend this journal