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Hand burns caused by electric fires
240
Injury,
4, 240-246
Hand burns caused by electric fires Philip A. Stone M.R.C. Industrial Injuries and Burns Research Unit. Birmingham Accident Hospital Summary Ninety cases of electric-tie burns of the hand treated at the Birmingham Accident Hospital Burns Unit between 1961 and 1970 are presented. There were 82 thermal and 8 electrical burns in 53 males and 37 females. The use of hreguards, type of electric tire, and mode of injury are analysed. Surgical management is discussed and data on early excision and grafting and late grafting are presented. The new British Standard Specification for fireguards of electric heating appliances should help to reduce these disabling accidents in the future.
elements of electric fire heaters, and Williams (1955) and Gunn (1967) have reviewed their experience with hand burns caused by electric fires. This paper reviews 90 injuries to hands caused by electric fires (82 thermal and 8 electrothermal or electrical), seen at the Birmingham Accident Hospital Burns Unit from 1961 to 1970. It is hoped that the data presented will help in the future evaluation of the efficiency of the new British Standard Specification for guards for electric heaters. METHODS OF REVIEW Between 1961 and 1970 there were approximately 3500 admission to the Burns Unit, and of these 90 (2.5 per cent) had sustained burns of the hand caused by electric heaters. Where information was lacking about the type of electric fire, the use of fireguards, and the mode of injury, questionnaires were sent out.
INTRODUCTION BURNSof the hand from electric tires continue to be a major problem in spite of increased awareness of the potential danger of these heating devices. In view of the high incidence of this type of injury, the British Standards Institution introduced in 1971 new specifications for the design and performance of guards for electric heaters. Ross (1950) reviewed his experience with the treatment of 323 recent burns of the hand, but the exact number of burns sustained on electric fire heaters was not mentioned. Davies (1959) reported 14 patients whose hands were burned on
RESULTS Analysis of the annual incidence shows a moving three-point average (Moroney, 1957), which suggests that there has been no major trend during the period under review (Fig. 1). The peak 19 18 17 16
... a
1961 1962 1963 1964 1965 Annual
1966
Moving 3.point . average - No. of patients
/flL 167 1968 1969 1970
inadence
Fig. 1.-Annual
incidence.
Stone:
incidence was in 1965-7. There was no clinical information to explain the drop from 19 to 1 in 1967. Study of the age distribution (Fig. 2) shows that more than half the patients (58 per cent) were between the ages of 2 and 3. Eleven adults (12 per cent) aged from 17 to 82 years sustained hand burns from electric fire heaters. All the children and 3 adults had true thermal burns. Eight adults had either electrothermal or electrical injuries. There were no other associated injuries and no deaths in this group of patients. Analysis of the sex incidence (Fig. 3) shows that 59 per cent were male and 41 per cent were female. In the infant and adolescent group males predominated 2 : 1, while in the adult groups the
Fig.
241
Hand Burns from Electric Fires
In this series 79 per cent, 3.4 per cent, and 3.4 per cent of the victims burned themselves on types A, B, and C respectively. The burns sustained on the silica-sheathed rod type of heater were less extensive and therefore less disabling than the others, but they were just as deep. The severity and pattern of hand burns caused by the silica-sheathed rod heating units may be reduced by their inaccessibility because these heating devices are usually fixed to walls above washbasins, baths, or mirrors. The effectiveness of electric f ireguards Seventy-nine per cent of the patients sustained their bums on fires which were said to have been
2.-Age incidence.
ratio was reversed. The fact that women are involved more often than men in switching on or cleaning electric fires during cold weather may explain their greater liability to injury. The information obtained on the use of electric fireguards, the type of electric fire, and the described mode of injury are detailed in Table I. Type of electric fire Three types of heating element may be found in the conventional electric fire:1. Type A, a wire coil wound round an exposed rod (Fig. 4). 2. -Type B, a wire coil arranged in parallel or zigzag in a fire-clay mount (Fig. 5). 3. Type C, a silica-sheathed rod.
Males
Females
Chtldren
O-15 y.
Ffg. 3.-Sex
incidence.
Males Adulrs
Females 16-82 yr
242
Injury: the British Journal of Accident
guarded, and 14.4 per cent received from unguarded fires.
Mode
their injuries
of injury
Many patients were alleged to have put their hand through the guard (39 per cent), while some lifted (22.1 per cent) and others removed (15.6 per cent) the guard in acquiring their injuries. As might be expected, injuries from putting the hand through the guard chiefly affected young children, but age was not obviously related to the type of fire or the presence of a guard. For instance, two examples of severe burns caused by type A guarded electric fire are shown in Fig. 6. Table II summarizes the data on burns of adult hands caused by electric fires. There were 11 adults, 4 males and 7 females. Only 3 of these sustained thermal burns; the remainder had electrical burns. Six adults were burned while cleaning, and 3 while repairing electric fires. One patient deliberately grabbed a glowing electric coil with both hands, while another patient Tab/e /.-Type
accidentally element.
brushed
his hand
Surgery Vol. ~/NO. 3
against
a red-hot
PRINCIPLES OF SURGICAL MANAGEMENT It is the practice of this unit to carry out wound closure as soon as possible. Whenever practical, early excision of eschar (usually within 4 days of injury) is followed by immediate cover with thick split-skin grafts. This group of patients usually present obvious whole-skin loss involving skin, or skin and underlying fat. By contrast there is a group of patients who may present with burns of questionable depth, or burns of such severity that involvement of muscle, tendon, or bone could not be ruled out. In this group we prefer delayed skin-grafting on a suitable granulating surface. Tab/e 111 summarizes the clinical information for these two groups of patients. The figures given for the average number of hospital days represent a mean for the acute and reconstructive
of electric
fire, guard status,
and mode
No. of patients Type of electric fire A. Coil around exposed rod B. Wire coil in fire-clay mount C. Silica-sheathed rod D. Unknown Electric fireguard status A. Said to be guarded B. Not guarded C. Unknown Mode of injury A. Put hand through guard B. Lifted guard up C. Removed guard D. No guard to prevent injury E. Unknown
of injury
Age range
Percentage of total
71 3 3 13
l-62 2- 8 2-47 1-82
79
71 13 6
1-62 1-82 1-37
79 14.4 6.7
35 20 14 12 9
I-IO 2-62 1-25 l-82 l-37
22.1 15.6 13.3 10.0
3.4 3.4 14.4
39.0
Stone
: Hand Burns from Electric Fires
243
period of in-patient treatment. They are not mean healing times because some of these patients left hospital before complete healing had occurred and the time of healing was in doubt. Sixty-two per cent of the group treated by early excision and 70 per cent of those treated by delayed grafting required further operation, which included partial phalangeal amputations (6 and 5 in the two groups), correction of multiple flexion contractures, and reconstruction of the web spaces. Surgical technique (operative and postoperative) Once it was decided to carry out early excision, the burned hand was dressed in a position of function with tulle gras impregnated with neomycin and chlorhexidine, gauze, cotton-wool, and crepe bandage. Various creams (silver nitrate, silver sulphadiazine, or silver nitrate and chlorhexidine) were applied locally if early excision was not indicated. A 7-day course of erythromycin and an injection of tetanus toxoid (0.5 ml.) were given as prophylaxis against streptococcal infection and tetanus. Otherwise, antibiotics were not employed as a matter of course. Excision was usually performed between 1 and 4 days after burning. It was not felt necessary to wait until oedema had subsided, but the hand was fully elevated until operation. Excision is carried out under general anaesthesia using a pneumatic tourniquet. The opposite thigh is prepared for the donor site. After completely excising the charred epidermis, the residual burned tissue appears white with a cherry-red border, 1 mm. wide. This is related to the deposition of fixed carbon-monoxide haemoglobin in tissue (Peacock and van Winkle, 1970) and should not be misinterpreted as viable skin. The excision is carried out in stages, first Tab/e //.-Clinical Case
attending to the palm and then to the fingers. The diagnosis of whole-skin loss is confirmed when reddish fat is encountered. This is thought to represent the zone of stasis (Jackson, 1969), and this appearance and the presence of thrombosed veins show how much tissue to excise (Fig. 7). It is rarely necessary to remove the complete layer of fat, thereby exposing the palmar fascia. This is most undesirable because the fatty layer protects the palmar surface. However, this is not the case with early excision on the dorsum of the hand or fingers. Here no attempt is made to preserve the thin layer of subcutaneous fat; excision is completed in the plane which exposes
Fig. 5.-Type B electric fire: wire coil arranged zigzag or parallel on a fire-clay mount.
information on adult hand burns caused by electric fires
Sex
Age
1 2 3 4 5 6 7
M. F. M. M. F. F. F.
37 25 39 32 23 21 16
8
M.
39
9 10 11
F. F. F.
62 47 82
Cause of injury Holding ’ cold ’ electric coil during repair Cleaning electric fire while ’ switched off ’ Repairing electric fire while ’ switched off ’ Accidentally brushed against glowing electric coil Cleaning electric fire while ’ switched off ’ Cleaning electric fire while ’ switched off ’ Tried to brush ash from glowing electric fire element Psychotic; deliberately grabbed glowing electric fire elements with both hands Cleaning electric fire while ’ switched off ’ Cleaning electric fire while ’ switched off ’ Repairing electric fire element while ’ switched off
Type of injury Electrical Electrical Electrical Thermal Electrical Electrical Thermal Thermal
’
Electrical Electrical Electrical
in
244
Injury: the British Journal of Accident
the deep fascia, and the large veins on the dorsum of the hand are preserved whenever possible. Often there is a 0.5-1.0 cm. layer of oedema on the dorsum of the hand. This is left undisturbed and grafts are placed directly on this oedematous tissue, where they take perfectly well. After excision of the palmar eschar the tourniquet is released so that maximal haemostasis can be obtained by diathermy before applying the grafts. The tourniquet is left deflated unless oozing from the skin edges continues. Moderately thick split-thickness grafts are applied. Following suitable fixation of the grafts with tie-over sutures or an extra wrapping of carefully placed tulle gras, compression is achieved by applying a layer of damp cottonwool, held in place with cotton bandage, dry wool and crepe bandage, with a plaster shell over all for extra immobilization. The initial plaster
Fig.
6.-Two
analysis
No. of patients
Early excision
holds the fingers and wrist in full extension and the elbow at 90” of flexion (Fig. 8). The first dressing is intended primarily to ensure good graft fixation, less emphasis being placed on prevention of flexion contractures. Dressings are changed at 6 days, and the new, much less bulky dressings ensure that the fingers are kept fully extended. When healing is complete, the plaster is reduced to below the elbow, with the fingers and wrist still in full extension (Fig. 9). The plaster is changed monthly and reinforced as necessary. Mothers are asked to return on the same day if the plaster comes off or becomes soft. All dressings are finally removed 3 months after operation. The postoperative care of adults is somewhat different. Dressings are placed with the fingers and hand in the position of function to avoid ankylosis in a nonfunctional position. When healing is sufficiently complete, active exercises assisted by the physiotherapist are begun. Adults are also encouraged to wear a dynamic glove which incorporates a thin whalebone splint on the dorsum of each finger, Thus any tendency towards flexion is in part counteracted by the splint.
examples of severe burns caused by type A electric fire.
Tab/e ///.-Comparative
Group
Surgery Vol. ~/NO. 3
of patients
Average no. of admissions
treated
by early excision
and delayed
Average no. of operations
Percentage requiring late surgery
grafting
No. of amputations
Average no. of hospital days
pezent)
2.1
2.4
62
6
34.2
56 per cent)
1.7
1.5
70
5
21.6
(38 -Delayed grafting (62
Stone:
Hand Burns from Electric Fires
On occasions, a finger slips into a flexed position inside a plaster. In such cases ilexion contracture develops very quickly, even within a week. Subsequent changes of dressing with tnoulding of the plaster can sometimes correct this early flexion contracture. Even after 3 months in plaster, some flexion contracture can still develop, but correction of these delayed contractures is usually postponed for 8-12 months until the grafts begin to soften. All secondary procedures are usually completed within 3 years of burning.
245
Secondary digital flexion contractures and contractures of web space were common delayed complications in this series. The flexlon contractures were corrected either by Z-plasty, with or without a Wolfe graft, or by a simple incision across the scar at right-angles to the long axis of the contracture. Correcting the contracture creates a diamond-shaped defect, which can be filled with a Wolfe graft. Neither hypertrophic scar nor normal skin at the end of these transverse incisions was excised, in an attempt to create a rectangular defect bordering on the radial and ulnar digital neutral lines. Skin shortage in the web space was corrected by re-forming the web with triangular flaps based on the dorsal and palmar skin. The defects thus created on the adjacent sides of the digits were covered with thick split-skin grafts.
DISCUSSION
7.-A stage in early excision of palmar eschar. In this case the darker areas indicate the deeper burned ’ red fat ’ in the zone of stasis. This must be excised before applying graft.
Fig.
Fig. S.-Initial plaster shown holding the fingers and wrist in full extension and the elbow at 90” flexion.
In Ross’s series 269 hand burns of all kinds were admitted on the day of injury. In this series it was not possible to identify those burns caused exclusively by electric fires. Sixty-four patients showed whole-skin loss. Fifty were treated by primary excision and grafting with a mean healing time of 25 days, while 13 patients had split-skin grafts applied to granulation tissue. This group showed a mean healing time of 40 days. Williams (1955) published a review of 100 cases of burned hands in children. Thirty-six of these were caused by electric fires but no information was given about the presence or absence of a guard, or about the mode of injury. Both the primarily excised and the delayed grafted groups showed a 70 per cent incidence of contractures. Those patients having primary excision had an average of two operations per patient and needed 6.5 hospital weeks for complete healing
Fig. 9.-Reduced
plaster with the fingers and wrist still in full extension.
246
Injury:
to occur. In the group treated initially by nonsurgical methods, there was an average of 1.4 operations and 8.5 hospital weeks for complete healing. The time between burning and beginning surgical repair of contractures ranged from 2 to 3 years. Less than a quarter of the patients were splinted after the first dressing change. Neither chronic oedema nor immobility of the fingers occurred in those treated with prolonged fixation (Ross, 1950). Davies reported 17 cases of hand burns caused by electric fires treated in 1951-5. These were all thermal injuries. Nine treated by primary excision and grafting healed in 20-30 days, while 7 patients treated by delayed grafting showed slightly longer healing times (30-70 days). Repeated operations were slightly more frequent in the primarily excised and grafted group but the final functional result was considered superior (Davies, 1959). Gunn published a series of 19 burns of the hand in children, caused by electric fires. Seventeen (90 per cent) required grafting, usually in the second or third week. Two (IO.5 per cent) had amputations of digits and 6 (35.3 per cent) had late operation for contractures. The average time required for healing was 5-6 weeks (Gunn, 1967). Gunn thought that injuries sustained on types B and C electric fires were less frequent and less severe than those on type A, and if a suitable guard could not be designed for type A fires they should be abandoned in favour of the fire-clay mounted or silica-sheathed type. The present series confirms the lower incidence of burns from fires of types B and C, but patients burned by type B fires require more operations (2-3) and an average of 2-3 admissions and a longer hospital stay (43 days) than those burned by type A fires. This was unexpected because it was considered impossible for children to grasp this type of element. However, if fires of type B are unguarded or inadequately guarded, the outstretched hand can sustain burns of an intensity similar to those caused by the exposed-rod type of fire (type A). The 3 patients burned by type C fires had an average of 1.3 operations and 7 days in hospital, which was considerably less than for either of the other groups. Prevention depends upon the introduction of better fireguards. The British Standards Institution has now published new design and performance requirements for electric heater guards (B.S. 1945: 1971) which state that ‘ No openmg shall have either: (a) a major dimension exceeding Requestsfor
repprints
should
be addressed
to:-Philip A. Stone,
the British Journal
of Accident
Surgery
Vol. ~/NO. 3
125 mm. and a minor dimension exceeding 12 mm., and a diagonal dimension exceeding 126 mm. : or (b) a major dimension exceeding 50 mm. and a minor dimension exceeding 20 mm. and a diagonal dimension exceeding 53 mm.’ also stated that ‘ the test finger (80 mm.It i: length) shall not touch any live parts when applied through any opening in the aperture to be protected, with a force not exceeding 5N.’ Guards with these specifications were recommended on new electric fires from 30 July, 1971. Because the new guard should prevent the examining finger or hand from touching a hot element, a large proportion of the injuries described above should be prevented. However, 22 per cent of patients in this series sustained burns after lifting the guard, and 15 per cent after removing the guard. It must be hoped that the newly constructed guards will not be so easily Unfortunately, many of the old removed. patterns of guards will continue in use in places where they are most likely to cause injury, and it may be some time before the benefits of the new British Standard are realized. Acknowledgements I am grateful to Col. Louis Rosenfield without whose financial assistance this work would not have been done. I am also indebted to Dr. J. P. Bull and Mr. D. M. Jackson for helpful criticism in preparation of this paper. Thanks are also due to Miss Gloria Simon and Miss Barbara Over for typing the manuscript, and to Mr. D. T. Johnson for early encouragement of this work.
REFERENCES BRITISH STANDARDS
INSTITUTION (1945
:
197 l),
Specification for fire guards for heating appliances (gas, electric and oil-burning). DAVIES, M. R. (1959), ‘ Burns caused by electricity: a review of seventy cases ‘, Br. J. plust. Surf., 11, 288. GUNN, A. (1967), ‘ The primary treatment of deep burns of the hand in children ‘, Guy’s Hosp. Rep., 116, 15. JACKSON.D. M. (1969). ‘ Second thoughts on the burn _ wound ‘, J. Trauma, 4, 839. MORONEY,M. J. (1957), Facts from Figures. Harmondsworth: Penguin. PEACOCK, E. E., jun., and VAN WINKLE, W., jun. (1970).
Surgery
and
Biology
qf
Wound
Repair.
Philadelphia: Saunders. Ross, W. P. D. (1950), ‘ The treatment of recent burns of the hand ‘, Br. J. plast. Surg., 2, 233. WILLIAMS, W. (1955), ‘ A review of burned hands in children ‘, Ibid., 7, 313.
Esq., M.D.,
I148
Main
Street,
Wakefield,
Massachusetts,
U.S.A.
Injury,
4, 240-246
Hand burns caused by electric fires Philip A. Stone M.R.C. Industrial Injuries and Burns Research Unit. Birmingham Accident Hospital Summary Ninety cases of electric-tie burns of the hand treated at the Birmingham Accident Hospital Burns Unit between 1961 and 1970 are presented. There were 82 thermal and 8 electrical burns in 53 males and 37 females. The use of hreguards, type of electric tire, and mode of injury are analysed. Surgical management is discussed and data on early excision and grafting and late grafting are presented. The new British Standard Specification for fireguards of electric heating appliances should help to reduce these disabling accidents in the future.
elements of electric fire heaters, and Williams (1955) and Gunn (1967) have reviewed their experience with hand burns caused by electric fires. This paper reviews 90 injuries to hands caused by electric fires (82 thermal and 8 electrothermal or electrical), seen at the Birmingham Accident Hospital Burns Unit from 1961 to 1970. It is hoped that the data presented will help in the future evaluation of the efficiency of the new British Standard Specification for guards for electric heaters. METHODS OF REVIEW Between 1961 and 1970 there were approximately 3500 admission to the Burns Unit, and of these 90 (2.5 per cent) had sustained burns of the hand caused by electric heaters. Where information was lacking about the type of electric fire, the use of fireguards, and the mode of injury, questionnaires were sent out.
INTRODUCTION BURNSof the hand from electric tires continue to be a major problem in spite of increased awareness of the potential danger of these heating devices. In view of the high incidence of this type of injury, the British Standards Institution introduced in 1971 new specifications for the design and performance of guards for electric heaters. Ross (1950) reviewed his experience with the treatment of 323 recent burns of the hand, but the exact number of burns sustained on electric fire heaters was not mentioned. Davies (1959) reported 14 patients whose hands were burned on
RESULTS Analysis of the annual incidence shows a moving three-point average (Moroney, 1957), which suggests that there has been no major trend during the period under review (Fig. 1). The peak 19 18 17 16
... a
1961 1962 1963 1964 1965 Annual
1966
Moving 3.point . average - No. of patients
/flL 167 1968 1969 1970
inadence
Fig. 1.-Annual
incidence.
Stone:
incidence was in 1965-7. There was no clinical information to explain the drop from 19 to 1 in 1967. Study of the age distribution (Fig. 2) shows that more than half the patients (58 per cent) were between the ages of 2 and 3. Eleven adults (12 per cent) aged from 17 to 82 years sustained hand burns from electric fire heaters. All the children and 3 adults had true thermal burns. Eight adults had either electrothermal or electrical injuries. There were no other associated injuries and no deaths in this group of patients. Analysis of the sex incidence (Fig. 3) shows that 59 per cent were male and 41 per cent were female. In the infant and adolescent group males predominated 2 : 1, while in the adult groups the
Fig.
241
Hand Burns from Electric Fires
In this series 79 per cent, 3.4 per cent, and 3.4 per cent of the victims burned themselves on types A, B, and C respectively. The burns sustained on the silica-sheathed rod type of heater were less extensive and therefore less disabling than the others, but they were just as deep. The severity and pattern of hand burns caused by the silica-sheathed rod heating units may be reduced by their inaccessibility because these heating devices are usually fixed to walls above washbasins, baths, or mirrors. The effectiveness of electric f ireguards Seventy-nine per cent of the patients sustained their bums on fires which were said to have been
2.-Age incidence.
ratio was reversed. The fact that women are involved more often than men in switching on or cleaning electric fires during cold weather may explain their greater liability to injury. The information obtained on the use of electric fireguards, the type of electric fire, and the described mode of injury are detailed in Table I. Type of electric fire Three types of heating element may be found in the conventional electric fire:1. Type A, a wire coil wound round an exposed rod (Fig. 4). 2. -Type B, a wire coil arranged in parallel or zigzag in a fire-clay mount (Fig. 5). 3. Type C, a silica-sheathed rod.
Males
Females
Chtldren
O-15 y.
Ffg. 3.-Sex
incidence.
Males Adulrs
Females 16-82 yr
242
Injury: the British Journal of Accident
guarded, and 14.4 per cent received from unguarded fires.
Mode
their injuries
of injury
Many patients were alleged to have put their hand through the guard (39 per cent), while some lifted (22.1 per cent) and others removed (15.6 per cent) the guard in acquiring their injuries. As might be expected, injuries from putting the hand through the guard chiefly affected young children, but age was not obviously related to the type of fire or the presence of a guard. For instance, two examples of severe burns caused by type A guarded electric fire are shown in Fig. 6. Table II summarizes the data on burns of adult hands caused by electric fires. There were 11 adults, 4 males and 7 females. Only 3 of these sustained thermal burns; the remainder had electrical burns. Six adults were burned while cleaning, and 3 while repairing electric fires. One patient deliberately grabbed a glowing electric coil with both hands, while another patient Tab/e /.-Type
accidentally element.
brushed
his hand
Surgery Vol. ~/NO. 3
against
a red-hot
PRINCIPLES OF SURGICAL MANAGEMENT It is the practice of this unit to carry out wound closure as soon as possible. Whenever practical, early excision of eschar (usually within 4 days of injury) is followed by immediate cover with thick split-skin grafts. This group of patients usually present obvious whole-skin loss involving skin, or skin and underlying fat. By contrast there is a group of patients who may present with burns of questionable depth, or burns of such severity that involvement of muscle, tendon, or bone could not be ruled out. In this group we prefer delayed skin-grafting on a suitable granulating surface. Tab/e 111 summarizes the clinical information for these two groups of patients. The figures given for the average number of hospital days represent a mean for the acute and reconstructive
of electric
fire, guard status,
and mode
No. of patients Type of electric fire A. Coil around exposed rod B. Wire coil in fire-clay mount C. Silica-sheathed rod D. Unknown Electric fireguard status A. Said to be guarded B. Not guarded C. Unknown Mode of injury A. Put hand through guard B. Lifted guard up C. Removed guard D. No guard to prevent injury E. Unknown
of injury
Age range
Percentage of total
71 3 3 13
l-62 2- 8 2-47 1-82
79
71 13 6
1-62 1-82 1-37
79 14.4 6.7
35 20 14 12 9
I-IO 2-62 1-25 l-82 l-37
22.1 15.6 13.3 10.0
3.4 3.4 14.4
39.0
Stone
: Hand Burns from Electric Fires
243
period of in-patient treatment. They are not mean healing times because some of these patients left hospital before complete healing had occurred and the time of healing was in doubt. Sixty-two per cent of the group treated by early excision and 70 per cent of those treated by delayed grafting required further operation, which included partial phalangeal amputations (6 and 5 in the two groups), correction of multiple flexion contractures, and reconstruction of the web spaces. Surgical technique (operative and postoperative) Once it was decided to carry out early excision, the burned hand was dressed in a position of function with tulle gras impregnated with neomycin and chlorhexidine, gauze, cotton-wool, and crepe bandage. Various creams (silver nitrate, silver sulphadiazine, or silver nitrate and chlorhexidine) were applied locally if early excision was not indicated. A 7-day course of erythromycin and an injection of tetanus toxoid (0.5 ml.) were given as prophylaxis against streptococcal infection and tetanus. Otherwise, antibiotics were not employed as a matter of course. Excision was usually performed between 1 and 4 days after burning. It was not felt necessary to wait until oedema had subsided, but the hand was fully elevated until operation. Excision is carried out under general anaesthesia using a pneumatic tourniquet. The opposite thigh is prepared for the donor site. After completely excising the charred epidermis, the residual burned tissue appears white with a cherry-red border, 1 mm. wide. This is related to the deposition of fixed carbon-monoxide haemoglobin in tissue (Peacock and van Winkle, 1970) and should not be misinterpreted as viable skin. The excision is carried out in stages, first Tab/e //.-Clinical Case
attending to the palm and then to the fingers. The diagnosis of whole-skin loss is confirmed when reddish fat is encountered. This is thought to represent the zone of stasis (Jackson, 1969), and this appearance and the presence of thrombosed veins show how much tissue to excise (Fig. 7). It is rarely necessary to remove the complete layer of fat, thereby exposing the palmar fascia. This is most undesirable because the fatty layer protects the palmar surface. However, this is not the case with early excision on the dorsum of the hand or fingers. Here no attempt is made to preserve the thin layer of subcutaneous fat; excision is completed in the plane which exposes
Fig. 5.-Type B electric fire: wire coil arranged zigzag or parallel on a fire-clay mount.
information on adult hand burns caused by electric fires
Sex
Age
1 2 3 4 5 6 7
M. F. M. M. F. F. F.
37 25 39 32 23 21 16
8
M.
39
9 10 11
F. F. F.
62 47 82
Cause of injury Holding ’ cold ’ electric coil during repair Cleaning electric fire while ’ switched off ’ Repairing electric fire while ’ switched off ’ Accidentally brushed against glowing electric coil Cleaning electric fire while ’ switched off ’ Cleaning electric fire while ’ switched off ’ Tried to brush ash from glowing electric fire element Psychotic; deliberately grabbed glowing electric fire elements with both hands Cleaning electric fire while ’ switched off ’ Cleaning electric fire while ’ switched off ’ Repairing electric fire element while ’ switched off
Type of injury Electrical Electrical Electrical Thermal Electrical Electrical Thermal Thermal
’
Electrical Electrical Electrical
in
244
Injury: the British Journal of Accident
the deep fascia, and the large veins on the dorsum of the hand are preserved whenever possible. Often there is a 0.5-1.0 cm. layer of oedema on the dorsum of the hand. This is left undisturbed and grafts are placed directly on this oedematous tissue, where they take perfectly well. After excision of the palmar eschar the tourniquet is released so that maximal haemostasis can be obtained by diathermy before applying the grafts. The tourniquet is left deflated unless oozing from the skin edges continues. Moderately thick split-thickness grafts are applied. Following suitable fixation of the grafts with tie-over sutures or an extra wrapping of carefully placed tulle gras, compression is achieved by applying a layer of damp cottonwool, held in place with cotton bandage, dry wool and crepe bandage, with a plaster shell over all for extra immobilization. The initial plaster
Fig.
6.-Two
analysis
No. of patients
Early excision
holds the fingers and wrist in full extension and the elbow at 90” of flexion (Fig. 8). The first dressing is intended primarily to ensure good graft fixation, less emphasis being placed on prevention of flexion contractures. Dressings are changed at 6 days, and the new, much less bulky dressings ensure that the fingers are kept fully extended. When healing is complete, the plaster is reduced to below the elbow, with the fingers and wrist still in full extension (Fig. 9). The plaster is changed monthly and reinforced as necessary. Mothers are asked to return on the same day if the plaster comes off or becomes soft. All dressings are finally removed 3 months after operation. The postoperative care of adults is somewhat different. Dressings are placed with the fingers and hand in the position of function to avoid ankylosis in a nonfunctional position. When healing is sufficiently complete, active exercises assisted by the physiotherapist are begun. Adults are also encouraged to wear a dynamic glove which incorporates a thin whalebone splint on the dorsum of each finger, Thus any tendency towards flexion is in part counteracted by the splint.
examples of severe burns caused by type A electric fire.
Tab/e ///.-Comparative
Group
Surgery Vol. ~/NO. 3
of patients
Average no. of admissions
treated
by early excision
and delayed
Average no. of operations
Percentage requiring late surgery
grafting
No. of amputations
Average no. of hospital days
pezent)
2.1
2.4
62
6
34.2
56 per cent)
1.7
1.5
70
5
21.6
(38 -Delayed grafting (62
Stone:
Hand Burns from Electric Fires
On occasions, a finger slips into a flexed position inside a plaster. In such cases ilexion contracture develops very quickly, even within a week. Subsequent changes of dressing with tnoulding of the plaster can sometimes correct this early flexion contracture. Even after 3 months in plaster, some flexion contracture can still develop, but correction of these delayed contractures is usually postponed for 8-12 months until the grafts begin to soften. All secondary procedures are usually completed within 3 years of burning.
245
Secondary digital flexion contractures and contractures of web space were common delayed complications in this series. The flexlon contractures were corrected either by Z-plasty, with or without a Wolfe graft, or by a simple incision across the scar at right-angles to the long axis of the contracture. Correcting the contracture creates a diamond-shaped defect, which can be filled with a Wolfe graft. Neither hypertrophic scar nor normal skin at the end of these transverse incisions was excised, in an attempt to create a rectangular defect bordering on the radial and ulnar digital neutral lines. Skin shortage in the web space was corrected by re-forming the web with triangular flaps based on the dorsal and palmar skin. The defects thus created on the adjacent sides of the digits were covered with thick split-skin grafts.
DISCUSSION
7.-A stage in early excision of palmar eschar. In this case the darker areas indicate the deeper burned ’ red fat ’ in the zone of stasis. This must be excised before applying graft.
Fig.
Fig. S.-Initial plaster shown holding the fingers and wrist in full extension and the elbow at 90” flexion.
In Ross’s series 269 hand burns of all kinds were admitted on the day of injury. In this series it was not possible to identify those burns caused exclusively by electric fires. Sixty-four patients showed whole-skin loss. Fifty were treated by primary excision and grafting with a mean healing time of 25 days, while 13 patients had split-skin grafts applied to granulation tissue. This group showed a mean healing time of 40 days. Williams (1955) published a review of 100 cases of burned hands in children. Thirty-six of these were caused by electric fires but no information was given about the presence or absence of a guard, or about the mode of injury. Both the primarily excised and the delayed grafted groups showed a 70 per cent incidence of contractures. Those patients having primary excision had an average of two operations per patient and needed 6.5 hospital weeks for complete healing
Fig. 9.-Reduced
plaster with the fingers and wrist still in full extension.
246
Injury:
to occur. In the group treated initially by nonsurgical methods, there was an average of 1.4 operations and 8.5 hospital weeks for complete healing. The time between burning and beginning surgical repair of contractures ranged from 2 to 3 years. Less than a quarter of the patients were splinted after the first dressing change. Neither chronic oedema nor immobility of the fingers occurred in those treated with prolonged fixation (Ross, 1950). Davies reported 17 cases of hand burns caused by electric fires treated in 1951-5. These were all thermal injuries. Nine treated by primary excision and grafting healed in 20-30 days, while 7 patients treated by delayed grafting showed slightly longer healing times (30-70 days). Repeated operations were slightly more frequent in the primarily excised and grafted group but the final functional result was considered superior (Davies, 1959). Gunn published a series of 19 burns of the hand in children, caused by electric fires. Seventeen (90 per cent) required grafting, usually in the second or third week. Two (IO.5 per cent) had amputations of digits and 6 (35.3 per cent) had late operation for contractures. The average time required for healing was 5-6 weeks (Gunn, 1967). Gunn thought that injuries sustained on types B and C electric fires were less frequent and less severe than those on type A, and if a suitable guard could not be designed for type A fires they should be abandoned in favour of the fire-clay mounted or silica-sheathed type. The present series confirms the lower incidence of burns from fires of types B and C, but patients burned by type B fires require more operations (2-3) and an average of 2-3 admissions and a longer hospital stay (43 days) than those burned by type A fires. This was unexpected because it was considered impossible for children to grasp this type of element. However, if fires of type B are unguarded or inadequately guarded, the outstretched hand can sustain burns of an intensity similar to those caused by the exposed-rod type of fire (type A). The 3 patients burned by type C fires had an average of 1.3 operations and 7 days in hospital, which was considerably less than for either of the other groups. Prevention depends upon the introduction of better fireguards. The British Standards Institution has now published new design and performance requirements for electric heater guards (B.S. 1945: 1971) which state that ‘ No openmg shall have either: (a) a major dimension exceeding Requestsfor
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125 mm. and a minor dimension exceeding 12 mm., and a diagonal dimension exceeding 126 mm. : or (b) a major dimension exceeding 50 mm. and a minor dimension exceeding 20 mm. and a diagonal dimension exceeding 53 mm.’ also stated that ‘ the test finger (80 mm.It i: length) shall not touch any live parts when applied through any opening in the aperture to be protected, with a force not exceeding 5N.’ Guards with these specifications were recommended on new electric fires from 30 July, 1971. Because the new guard should prevent the examining finger or hand from touching a hot element, a large proportion of the injuries described above should be prevented. However, 22 per cent of patients in this series sustained burns after lifting the guard, and 15 per cent after removing the guard. It must be hoped that the newly constructed guards will not be so easily Unfortunately, many of the old removed. patterns of guards will continue in use in places where they are most likely to cause injury, and it may be some time before the benefits of the new British Standard are realized. Acknowledgements I am grateful to Col. Louis Rosenfield without whose financial assistance this work would not have been done. I am also indebted to Dr. J. P. Bull and Mr. D. M. Jackson for helpful criticism in preparation of this paper. Thanks are also due to Miss Gloria Simon and Miss Barbara Over for typing the manuscript, and to Mr. D. T. Johnson for early encouragement of this work.
REFERENCES BRITISH STANDARDS
INSTITUTION (1945
:
197 l),
Specification for fire guards for heating appliances (gas, electric and oil-burning). DAVIES, M. R. (1959), ‘ Burns caused by electricity: a review of seventy cases ‘, Br. J. plust. Surf., 11, 288. GUNN, A. (1967), ‘ The primary treatment of deep burns of the hand in children ‘, Guy’s Hosp. Rep., 116, 15. JACKSON.D. M. (1969). ‘ Second thoughts on the burn _ wound ‘, J. Trauma, 4, 839. MORONEY,M. J. (1957), Facts from Figures. Harmondsworth: Penguin. PEACOCK, E. E., jun., and VAN WINKLE, W., jun. (1970).
Surgery
and
Biology
qf
Wound
Repair.
Philadelphia: Saunders. Ross, W. P. D. (1950), ‘ The treatment of recent burns of the hand ‘, Br. J. plast. Surg., 2, 233. WILLIAMS, W. (1955), ‘ A review of burned hands in children ‘, Ibid., 7, 313.
Esq., M.D.,
I148
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Street,
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U.S.A.