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Early surgical treatment of severe electrical injury of bilateral upper extremities: a case report
24
Burns, 9.24-29
Printedin
Great hifain
Early surgical treatment of severe electrical injury of bilateral upper extremities: a case report Wang Xue-Wei,
Wang Naize and Lu Changshun
Department of Burns, Beijing Jishuitan Hospital, Beijing, China
Lu Chia Tse, Wei Jianing, In Daching and Jia Shulan Department of Traumatology and Orthopaedics, Beijing Jishuitan Hospital, BeJing, China
Summary
A patient with both upper limbs injured by highvoltage current was treated by early wound dtbridement, segmental excision of the necrosed humerus of the left upper arm, internal screw fixation and vascularized skin free grafting on the right wrist. Functional
recovery were satisfactory. IN electrical bums the upper limbs are most frequently injured. Despite the limited extent involved, deep tissues can be badly damaged, including massive muscular necrosis and severe injury to the nerve, blood vessel, tendon and bone, leading to functional disturbances of the injured limbs and even amputation. We treated a case of high-voltage current injury to both upper limbs by early wound debridement, segmental excision of the necrosed humerus of the left upper arm, internal screw fixation and free skin grafting on the right wrist. Functional recovery of both upper limbs was satisfactory.
CASE REPORT A 33-year-old man was admitted to our hospital on the second day after an injury sustained from a high tension current of 10 000 V on 7 June 1978. Examination revealed that the skin and muscles in the radial aspect of the right wrist and thenar area were destroyed (Fig. l), radial artery pulsation was feeble and both sensory and motor functions of the median and ulnar nerves were lost. The lateral surface of the left upper
arm had also been in contact with high tension wires, causing irregular ring-shaped wounds in the region from the lower middle third up to above the elbow joint. Portions of normal skin remained only on the medial aspect, the shortest being 2 cm. An oblique fissure was found on the lateral side with dead muscles extruded, and the humerus was exposed for 3 cm, the periosteum being dead and separated, and bone colour darkened (Fig. 2). The left hand was swollen; sensory and motor functions of the radial nerve were absent but the circulation was normal. In addition, small deep burns were noted on the right lower abdomen, lefi leg and dorsum of the right foot. Four days after injury, debridement was performed on the left upper arm under brachial plexus block and continuous epidural anesthesia. At operation, the part of the biceps brachii found necrotic and ruptured with putrefied exudate was resected and the incision extended upward, only to reveal a state of ‘cooked meat’ necrosis of the lateral head ofthe triceps brachii, which was likewise resected. The humerus was then exposed for 6 cm and its dead and separated periosteum extended proximally and distally. As adjacent muscles were dead and the bone appeared dark grey with the radial nerve dead and fragmented, and since pulsation of the radial artery was only felt on the medial aspect, a thorough dtbridement had to be performed (Fig. 3). The dead humeral segment (5 cm) was excised, and the proximal lateral end and the distal medial end were obliquely constructed to enable endto-end apposition (Fig. 4). This done, fixation with two screws was employed (Fig. 5) and a good coverage was provided with surrounding normal muscle (Fig. 6) and with free skin grafts. Meanwhile, resection of the necrosed tissues on the radial side ofthe right wrist and
Wang Xue-Wei
et al.: Early surgical treatment
of severe electrical
Fig. I. The skin and muscles in the radial aspect of the right wrist and thenar area were destroyed.
injury of bilateral upper extremities
25
Fig. 2. The left upper arm had irregular ring-shaped wounds in the region from the lower middle third up to above the elbow joint. An oblique fissure was found on the lateral side with dead muscles extruded, and the humerus was exposed for 3 cm, the periosteum dead and separated and bone colour darkened.
* k
i
P[g. 3. Four days after injury, after a thorough debridement, the humerus was exposed for 6 cm. umeral segment (5 cm) was excused.
-
Fig. 5. The segmented ends were fixed with two screws.
Fig. 6. A good coverage was provided wtth surrounding normal muscle.
26
Fig. 7. Four days after injury, resection of the necrosed tissues on the radial side of the right wrist and the thenar majar was carried out.
Fig. 9. Left free dorsalis flap transfer to the right wrist with microvascular anastomoses.
Burns Vol. g/No. 1
Fig. 8. A piece of skin (10x 13 cm) taken from the dorsum of the left foot, and carrying proximally the anterior tibia1 artery and the great saphenous vein (3 and 4 mm in diameter respectively).
Fig. 10. X-ray, 4f months after the operation, revealed osteoporosis of the left humerus and absorption at the approximate ends, but callus formation was absent.
Wang Xue-Wei
et al.: Early surgical treatment of severe electrical injury of bilateral upper extremities
Fig.
skin
1 I.
A
pedicle
from
the
left thorax
(I 9 x 14 cm) was transplanted to the left arm. the thenar major was carried out. The wounds and exudates had an awful odour. The proximal transverse ligament of the wrist was incised and the median nerve at the proximal wrist canal, though pale and swollen for 5 cm, was still preserved. The superficial branch of the radial artery was thrombosed but the main artery itself was spared except that it was engorged and bluish-grey in colour over a distance of 2cm. The cephalic vein was patent proximally. Dead muscles, including the extensor pollicis longus, abductor pollicis brevis, flexor pollicis brevis, flexor digitorum profundus and sublimis, were only partially resected so as to maintain the continuity of the muscle tendons. The dead superficial layer of the pronator quadratus was also removed. The styloid process of the radius was burned, so it was partially resected, leaving exposed the first carpometacarpal joint. The skin defect was 7 x 10 cm (Fig. 7). An island flap of skin (10 x I3 cm) taken from the dorsum of the leti foot, and carrying proximally the anterior tibia1 artery and the great saphenous vein (3 and 4 mm in diameter respectively) (Fig. 8) was grahed through anastomosing the transferred vessels to the proximal ends of the right radial artery and cephalic vein (3 and 4 mm in diameter respectively). Wound closure was effected with excellent blood circulation to the grafted skin (Fig. 9). The dead whole-thickness skin of the left leg and right lower abdomen were also debrided and free skin grabs applied. After operation, the island flap skin graft at the right wrist took well and the skin grafts on the left upper extremities all survived. Four and a half months aher the operation, X-rays revealed osteoporosis of the left humerus and absorption at the approximate ends, but
27
Fig. 12. One month after above operation, the pedtcle was severed. callus formation was absent (Fig. IO). In order to obtain a further understanding of the blood circulation to the left humerus, an isotope scan of Ybr69 was performed and relatively high concentration of radioactivity were obtained as compared with the normal side.
Fig 13. x .-ray films 6 months after the injury sho wed callus forr nation at the left humerus, and the two cut ends were reunited.
Burns
a
b
Fig. 14. a and b, Eleven months after injury, left arm function was recovered satisfactorily.
a Fig.
b
15.u and b, One year after injury, right hand function was recovered basically.
Vol. g/No.
1
Wang Xue-Wei et al.: Early surgical treatment of severe electrical injury of bilateral upper extremities
To improve circulation and promote bony reunion, the grafted skin and surrounding scarring on the left arm were resected. A skin pedicle flap from the left thorax (19 x 14 cm) was transplanted (Fig. 1 I) and I month later the pedicle was severed (Fig. 12). X-ray films 6 months after the injury showed marked growth of callus at the left humerus, and the two cut ends were basically reunited (IQ. 13). Seven months after injury a tendon transplant was moved to the left arm and, postoperatively, wrist, thumb and digital extension were satisfactory (Fig. 14). Three months after injury to the right hand, electromyograms showed total damage of the median nerve below the wrist without any sign of recovery and partial damage of the ulnar nerve. Six months after injury the abductor pollicis brevis muscle was partly innervated. Ulnar nerve function was further improved as compared with the electromyograms 3 months before. After 1 year right hand function was recovered fully (Fig. 15). DISCUSSION This case had irregular ring-shaped wounds of the left arm with extensive
deep
muscle’ necrosis. The middle segment of the humerus was exposed for a length of 6 cm. In dealing with this type of wounded limb, the conventional method of early debridement of extensively destroyed muscles was unsatisfactory and it was difficult to effect skin coverage in one stage. Conservative treatment can often result in handicapped function or even amputation. In this case. we resorted to thorough debridement, excision of the exposed dead humerus and internal fixation, all of which made possible a good coverage with the surrounding normal muscle and a complete closure of the wound surface in one stage. In spite of the delayed bone healing and the shorter length of the arm, the limb was preserved and the functional recovery was also satisfactory. Although the injured humeral artery causes some impairment of the blood circulation, limb necrosis may be avoided by immediate excision of the injured blood vessels and by anastomosis or vessel grafting. This patient sustained a full-thickness electrical burn on the right wrist, with injury to the muscles, tendons, nerves, blood vessels and joints. Previously, such an injury would have been treated with abdominal skin pedicle grafts (Burn Unit, 1973) long term fixation and repeated operations. At the beginning of 1978, we first used microsurgical techniques to repair
29
early fresh burn wounds (Wang et al., 1978). The method of free skin pedicle from the dorsum of the foot, as employed in this case, not only diminishes the setbacks of long term fixation of the old method, but eliminates the wound once and for all, which obviously shortens the course of treatment and enables the implementation of early functional exercises. Compared with the free skin pedicle grafts from other areas, a pedicle from the dorsum of the foot can offer longer blood vessels, which can be readily anastomosed to the blood vessels of the recipient site. If blood vessels of the recipient site are injured, they should be thoroughly resected and the skin graft anastomosed to the proximal end of the forearm. This may avoid a possible massive haemorrhage due to disruption of the anastomosis as the resection of injured blood vessels is incomplete, and the operation can be performed macroscopically as the vessels are larger at the proximal ends. In this case, as the wound was on the radial side with the radial artery branch thrombosed only, although the trunk was grossly involved, the ulnar artery was still intact and the blood circulation of the hand was normal. The proximal end of the radial artery, therefore, was selected as the recipient. If both ulnar and radial arteries had been injured, leading to disturbance of the blood supply to the hand, ulnar and/or radial arterial transplantation would have been necessary to restore circulation to the wrist (Wang et al., 198 1). It is important that there should be no circulatory disturbance when free pedicle grafts are employed to cover wounds.
REFERENCES
Burn Unit, Department of Traumatology and Orthopedics. Beijing Jishuitan Hospital (1973) Treatment of electric burns (analysis on 246 cases). Chin. Med. J. 53, 213. Wang Xue-wei et al. (1978) Free pedis flap transplantation i,~ repair of deep electric injury (report of 3 cases). 51: Ninth National Congress of Surgery, Chinese ,tiedical Association, p. I 12. Wang X le-wei (1981) Early vascular grafting to prevent upper extremity necrosis after electrical burns. Ckdn. Med. J. 94, 185. Paper accepted 2 February 1982.
(‘owey~ondencc~ thou/d ho uddrrssed lo: Dr Wang Xue-Wei. c/o J. A. Boswick jun., 4200 E. 9th Avenue. Box C-309. Denver, Colorado 80262. USA.
Burns, 9.24-29
Printedin
Great hifain
Early surgical treatment of severe electrical injury of bilateral upper extremities: a case report Wang Xue-Wei,
Wang Naize and Lu Changshun
Department of Burns, Beijing Jishuitan Hospital, Beijing, China
Lu Chia Tse, Wei Jianing, In Daching and Jia Shulan Department of Traumatology and Orthopaedics, Beijing Jishuitan Hospital, BeJing, China
Summary
A patient with both upper limbs injured by highvoltage current was treated by early wound dtbridement, segmental excision of the necrosed humerus of the left upper arm, internal screw fixation and vascularized skin free grafting on the right wrist. Functional
recovery were satisfactory. IN electrical bums the upper limbs are most frequently injured. Despite the limited extent involved, deep tissues can be badly damaged, including massive muscular necrosis and severe injury to the nerve, blood vessel, tendon and bone, leading to functional disturbances of the injured limbs and even amputation. We treated a case of high-voltage current injury to both upper limbs by early wound debridement, segmental excision of the necrosed humerus of the left upper arm, internal screw fixation and free skin grafting on the right wrist. Functional recovery of both upper limbs was satisfactory.
CASE REPORT A 33-year-old man was admitted to our hospital on the second day after an injury sustained from a high tension current of 10 000 V on 7 June 1978. Examination revealed that the skin and muscles in the radial aspect of the right wrist and thenar area were destroyed (Fig. l), radial artery pulsation was feeble and both sensory and motor functions of the median and ulnar nerves were lost. The lateral surface of the left upper
arm had also been in contact with high tension wires, causing irregular ring-shaped wounds in the region from the lower middle third up to above the elbow joint. Portions of normal skin remained only on the medial aspect, the shortest being 2 cm. An oblique fissure was found on the lateral side with dead muscles extruded, and the humerus was exposed for 3 cm, the periosteum being dead and separated, and bone colour darkened (Fig. 2). The left hand was swollen; sensory and motor functions of the radial nerve were absent but the circulation was normal. In addition, small deep burns were noted on the right lower abdomen, lefi leg and dorsum of the right foot. Four days after injury, debridement was performed on the left upper arm under brachial plexus block and continuous epidural anesthesia. At operation, the part of the biceps brachii found necrotic and ruptured with putrefied exudate was resected and the incision extended upward, only to reveal a state of ‘cooked meat’ necrosis of the lateral head ofthe triceps brachii, which was likewise resected. The humerus was then exposed for 6 cm and its dead and separated periosteum extended proximally and distally. As adjacent muscles were dead and the bone appeared dark grey with the radial nerve dead and fragmented, and since pulsation of the radial artery was only felt on the medial aspect, a thorough dtbridement had to be performed (Fig. 3). The dead humeral segment (5 cm) was excised, and the proximal lateral end and the distal medial end were obliquely constructed to enable endto-end apposition (Fig. 4). This done, fixation with two screws was employed (Fig. 5) and a good coverage was provided with surrounding normal muscle (Fig. 6) and with free skin grafts. Meanwhile, resection of the necrosed tissues on the radial side ofthe right wrist and
Wang Xue-Wei
et al.: Early surgical treatment
of severe electrical
Fig. I. The skin and muscles in the radial aspect of the right wrist and thenar area were destroyed.
injury of bilateral upper extremities
25
Fig. 2. The left upper arm had irregular ring-shaped wounds in the region from the lower middle third up to above the elbow joint. An oblique fissure was found on the lateral side with dead muscles extruded, and the humerus was exposed for 3 cm, the periosteum dead and separated and bone colour darkened.
* k
i
P[g. 3. Four days after injury, after a thorough debridement, the humerus was exposed for 6 cm. umeral segment (5 cm) was excused.
-
Fig. 5. The segmented ends were fixed with two screws.
Fig. 6. A good coverage was provided wtth surrounding normal muscle.
26
Fig. 7. Four days after injury, resection of the necrosed tissues on the radial side of the right wrist and the thenar majar was carried out.
Fig. 9. Left free dorsalis flap transfer to the right wrist with microvascular anastomoses.
Burns Vol. g/No. 1
Fig. 8. A piece of skin (10x 13 cm) taken from the dorsum of the left foot, and carrying proximally the anterior tibia1 artery and the great saphenous vein (3 and 4 mm in diameter respectively).
Fig. 10. X-ray, 4f months after the operation, revealed osteoporosis of the left humerus and absorption at the approximate ends, but callus formation was absent.
Wang Xue-Wei
et al.: Early surgical treatment of severe electrical injury of bilateral upper extremities
Fig.
skin
1 I.
A
pedicle
from
the
left thorax
(I 9 x 14 cm) was transplanted to the left arm. the thenar major was carried out. The wounds and exudates had an awful odour. The proximal transverse ligament of the wrist was incised and the median nerve at the proximal wrist canal, though pale and swollen for 5 cm, was still preserved. The superficial branch of the radial artery was thrombosed but the main artery itself was spared except that it was engorged and bluish-grey in colour over a distance of 2cm. The cephalic vein was patent proximally. Dead muscles, including the extensor pollicis longus, abductor pollicis brevis, flexor pollicis brevis, flexor digitorum profundus and sublimis, were only partially resected so as to maintain the continuity of the muscle tendons. The dead superficial layer of the pronator quadratus was also removed. The styloid process of the radius was burned, so it was partially resected, leaving exposed the first carpometacarpal joint. The skin defect was 7 x 10 cm (Fig. 7). An island flap of skin (10 x I3 cm) taken from the dorsum of the leti foot, and carrying proximally the anterior tibia1 artery and the great saphenous vein (3 and 4 mm in diameter respectively) (Fig. 8) was grahed through anastomosing the transferred vessels to the proximal ends of the right radial artery and cephalic vein (3 and 4 mm in diameter respectively). Wound closure was effected with excellent blood circulation to the grafted skin (Fig. 9). The dead whole-thickness skin of the left leg and right lower abdomen were also debrided and free skin grabs applied. After operation, the island flap skin graft at the right wrist took well and the skin grafts on the left upper extremities all survived. Four and a half months aher the operation, X-rays revealed osteoporosis of the left humerus and absorption at the approximate ends, but
27
Fig. 12. One month after above operation, the pedtcle was severed. callus formation was absent (Fig. IO). In order to obtain a further understanding of the blood circulation to the left humerus, an isotope scan of Ybr69 was performed and relatively high concentration of radioactivity were obtained as compared with the normal side.
Fig 13. x .-ray films 6 months after the injury sho wed callus forr nation at the left humerus, and the two cut ends were reunited.
Burns
a
b
Fig. 14. a and b, Eleven months after injury, left arm function was recovered satisfactorily.
a Fig.
b
15.u and b, One year after injury, right hand function was recovered basically.
Vol. g/No.
1
Wang Xue-Wei et al.: Early surgical treatment of severe electrical injury of bilateral upper extremities
To improve circulation and promote bony reunion, the grafted skin and surrounding scarring on the left arm were resected. A skin pedicle flap from the left thorax (19 x 14 cm) was transplanted (Fig. 1 I) and I month later the pedicle was severed (Fig. 12). X-ray films 6 months after the injury showed marked growth of callus at the left humerus, and the two cut ends were basically reunited (IQ. 13). Seven months after injury a tendon transplant was moved to the left arm and, postoperatively, wrist, thumb and digital extension were satisfactory (Fig. 14). Three months after injury to the right hand, electromyograms showed total damage of the median nerve below the wrist without any sign of recovery and partial damage of the ulnar nerve. Six months after injury the abductor pollicis brevis muscle was partly innervated. Ulnar nerve function was further improved as compared with the electromyograms 3 months before. After 1 year right hand function was recovered fully (Fig. 15). DISCUSSION This case had irregular ring-shaped wounds of the left arm with extensive
deep
muscle’ necrosis. The middle segment of the humerus was exposed for a length of 6 cm. In dealing with this type of wounded limb, the conventional method of early debridement of extensively destroyed muscles was unsatisfactory and it was difficult to effect skin coverage in one stage. Conservative treatment can often result in handicapped function or even amputation. In this case. we resorted to thorough debridement, excision of the exposed dead humerus and internal fixation, all of which made possible a good coverage with the surrounding normal muscle and a complete closure of the wound surface in one stage. In spite of the delayed bone healing and the shorter length of the arm, the limb was preserved and the functional recovery was also satisfactory. Although the injured humeral artery causes some impairment of the blood circulation, limb necrosis may be avoided by immediate excision of the injured blood vessels and by anastomosis or vessel grafting. This patient sustained a full-thickness electrical burn on the right wrist, with injury to the muscles, tendons, nerves, blood vessels and joints. Previously, such an injury would have been treated with abdominal skin pedicle grafts (Burn Unit, 1973) long term fixation and repeated operations. At the beginning of 1978, we first used microsurgical techniques to repair
29
early fresh burn wounds (Wang et al., 1978). The method of free skin pedicle from the dorsum of the foot, as employed in this case, not only diminishes the setbacks of long term fixation of the old method, but eliminates the wound once and for all, which obviously shortens the course of treatment and enables the implementation of early functional exercises. Compared with the free skin pedicle grafts from other areas, a pedicle from the dorsum of the foot can offer longer blood vessels, which can be readily anastomosed to the blood vessels of the recipient site. If blood vessels of the recipient site are injured, they should be thoroughly resected and the skin graft anastomosed to the proximal end of the forearm. This may avoid a possible massive haemorrhage due to disruption of the anastomosis as the resection of injured blood vessels is incomplete, and the operation can be performed macroscopically as the vessels are larger at the proximal ends. In this case, as the wound was on the radial side with the radial artery branch thrombosed only, although the trunk was grossly involved, the ulnar artery was still intact and the blood circulation of the hand was normal. The proximal end of the radial artery, therefore, was selected as the recipient. If both ulnar and radial arteries had been injured, leading to disturbance of the blood supply to the hand, ulnar and/or radial arterial transplantation would have been necessary to restore circulation to the wrist (Wang et al., 198 1). It is important that there should be no circulatory disturbance when free pedicle grafts are employed to cover wounds.
REFERENCES
Burn Unit, Department of Traumatology and Orthopedics. Beijing Jishuitan Hospital (1973) Treatment of electric burns (analysis on 246 cases). Chin. Med. J. 53, 213. Wang Xue-wei et al. (1978) Free pedis flap transplantation i,~ repair of deep electric injury (report of 3 cases). 51: Ninth National Congress of Surgery, Chinese ,tiedical Association, p. I 12. Wang X le-wei (1981) Early vascular grafting to prevent upper extremity necrosis after electrical burns. Ckdn. Med. J. 94, 185. Paper accepted 2 February 1982.
(‘owey~ondencc~ thou/d ho uddrrssed lo: Dr Wang Xue-Wei. c/o J. A. Boswick jun., 4200 E. 9th Avenue. Box C-309. Denver, Colorado 80262. USA.