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Paediatric electrical burn: outlet injury caused by steel chopstick misuse
Burns 30 (2004) 244–247
Paediatric electrical burn: outlet injury caused by steel chopstick misuse Jong-wook Lee∗ , Young-chul Jang, Suk-joon Oh The Bum Unit, Department of Plastic & Reconstructive Surgery, Hangang Sacred Heart Hospital, Hallym University, Seoul, South Korea Received 9 October 2003; accepted 23 October 2003
Abstract Electrical burn in children in compared with adults is rare due to less chance of exposure to electricity. Although studies have been reported regarding pediatric electrical injury, there are no reports concerning outlet injury, especially those suffered by placing a steel chopstick as conducting material into the wall socket. Steel chopsticks are widely used for eating food in Korea. Children have sometimes injured themselves by inserting these into wall sockets (220 V). A retrospective study was conducted to obtain information about the characteristics of pediatric electrical injury resulting from steel chopstick misuse between January 1996 to June 2002. A total of 57 children with outlet injury were involved. Wounds were multiple and localized within the hand. The prevalent age was about 3 years old. The children studied with low voltage minor electrical injuries were deeply injured, had a high operation rate and remarkable sequelae, although wounds were small and localized. © 2003 Elsevier Ltd and ISBI. All rights reserved. Keywords: Paediatric electrical burn; Steel chopstick
1. Introduction In our hospital, 100 patients are admitted annually with electrical burns. All major electrical accidents occur in the industrial field. Low voltage household injury has been decreased due to product surveillance. However, there is still a problem of electrical outlet injuries. Although there have been some reports about electrical outlet injuries, there has been no reports about pediatric electrical burn suffered by placing a steel chopstick as conducting material into the electrical socket. Chopsticks made of plastic or wood are used for eating food internationally, but steel chopsticks are popular in Korea (Fig. 1). Sometimes children play with these chopsticks that may be easily inserted, due to the long slender shape, into the wall socket (220 V, two pins in our country). The present study was undertaken to identify the characteristics of this electrical outlet injury. 2. Material and methods From January 1996 to June 2002, the records of 63 children with electrical burn who were admitted to our unit were ∗
Corresponding author. Tel.: +82-2-2639-5780; fax: +82-2-2672-9684. E-mail address: [email protected] (J.-w. Lee).
0305-4179/$30.00 © 2003 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2003.10.012
traced. Among them six injured by other etiologies were discarded. A total of 57 children with electrical injury by chopstick misuse were investigated. A retrospective analysis of age and sex distribution, prevalent age and injury site, length of stay, cardiac abnormality, laboratory and electrocardiogram (EKG) data, treatment methods and late outcomes of individual fingers was made.
3. Results Fifty-seven children with electrical outlet injuries were treated at Hangang Sacred Heart Center for Burns and Plastic Surgery over the 6-year Study period. Among them, 33 were male and 24 were female. Their ages were ranged from 1 to 10 years with the commonest occurrence at age 3 (Table 1). There was no abnormality in EKG monitoring, blood chemistry study for creatinine phosphokinase (CPK) level, and urine analysis for myoglobinuria in all patients. All patients injured their hand, other sites were spared. Both hands were involved in 75.4% (Table 2). A total of 202 digits were injured, and burn wounds were multiple and localized (Fig. 2). Total hospital stay was 26 days in average with a mean of 11 days in those conservative treatment and 32 days in those undergoing surgical treatment.
J.-w. Lee et al. / Burns 30 (2004) 244–247
245
Table 1 Age distribution of electrical outlet injuries Age (years)
Number of patients
1 2 3 4 5 6 7 8 9 10
3 8 23 12 3 1 2 2 1 1
Total
57
Fig. 2. Characteristic appearance of chopstick outlet injury. Wounds with severity are multiple and localized within the hand.
Table 3 Treatment methods of injured individual fingers Methods
No. of digits
Conservative Skin graft Local or regional flap Distant flap Island flap Amputation
61 118 3 3 12 5
Total
202
Table 4 Outcomes after treatment Fig. 1. Steel chopsticks for eating food.
Conservative management was used in 16 (28%) out of 57 patients. Forty-one patients underwent operative procedures in 141 digits including STSG, FTSG, local flap, distant flap, island flap, amputation, etc. (Table 3). Among 57 patients, there were post-burn scar contractures in 12 patients, germinal matrix injury in 1, joint angulation deformity in 5 (Fig. 3), growth retardation due to epiphyseal plate injury in 2 (Fig. 4), joint ankylosis in 2, and loss of digit in 5 (Fig. 5) (Table 4).
Table 2 Injury sites of outlet injuries Injury site
No. of patients
Both hands Right hand only Left hand only
43 6 8
Total
57
Percentage (%) 75.4 10.6 14.0 100
Scar contracture Germinal matrix injury Angulation deformity Growth retardation Joint ankylosis Loss of digit
No. of patients
No. of digits
12 1 5 2 2 5
39 1 6 2 2 5
4. Discussion Generally, the resultant damage of electrical burn depends on the type and intensity of current, the tissue resistance, the pathway of flow, and the duration of contact, however, common etiologies of electrical burns in children differ from those of adults. Electrical burns occur typically in poorly supervised or unattended children [1]. These are usually low voltage injuries resulting from placing a metal object into an electrical socket, biting an electrical cord (oral injury), or contacting the low voltage wire or from an appliance. Oral electrical injuries have decreased in recent years while outlet injuries have increased. Although generally Electrical outlet injuries represent less than 15% of all pediatric electrical injuries [1,2], most of our patients had outlet injuries due to the unique culture using steel chopsticks for eating food.
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J.-w. Lee et al. / Burns 30 (2004) 244–247
Fig. 3. This child had angulation deformity in his right 3, 4 fingers (left). X-ray shows damage close to PIP joint (right).
Most of the patients, especially children with electrical injuries had a justified admission due to the severity of the injury, but admission requirements are controversial for patients who have sustained low voltage injuries [3,4].
There have been reports concerning patients with outlet injury in children with electrical injury [3,5], but there were no children who had sustained an outlet injury by placing steel (metal) chopsticks in the socket. In one study CPK and EKG abnormality were noted in one patient, respectively,
Fig. 4. A child with epiphyseal plate injury in his left middle finger (above). Growth retardation after epiphyseal injury, the right index is small as compared with contralateral finger (below).
J.-w. Lee et al. / Burns 30 (2004) 244–247
247
Fig. 5. The right little finger was mummified due to severe damage (left). Postoperative view after operation (right).
and urine analysis were normal in all [3]. In our series, abnormal findings were not noted in CPK, EKG, and urine analysis. Zubair et al. [3] reported all patients with outlet injuries were treated conservatively without any operative procedure. However, most of our patients had deep second to third degree burn injuries. Forty-one children (72%) among our patients had operative procedures including skin graft and flap surgery due to the severity of the injuries. This demonstrates that greater necrosis occurred in our series in spite of these being low voltage injury. In addition, according to careful follow up after wound healing, specific outcomes close to and involving finger joints were noted. There were angulation deformities and epiphyseal plate injuries due to deep tissue necrosis. Children in our study had a high incidence of outlet injuries in comparison with other studies. The low position of the wall socket, the absence of a blanking plug for socket, and the use of steel chopstick as a conductor. We have advocated high placing of wall socket out of reach of children predispose to these serious injuries an legislation to encourage the use of blanking plugs. Although it can be regarded as
a minor hand burn, the outlet electrical injury resulting from placing steel chopsticks into an electrical socket commonly needs operative procedures. It also can cause cosmetic and functional problems, especially loss of digits, joint angulation, and growth retardation. These types of injuries can be prevented by utilizing simple safety measure together with good supervision of younger children and education concerning electrical hazards in general. References [1] Baker MD, Chiaviello C. Household electrical injuries in children. Epidemiology and identification of avoidable hazards. AJDC 1989;143:59–62. [2] Garcia CT, Smith GA, Cohen DM, Fernandez K. Electrical injuries in a pediatric emergency department. Ann Emerg Med 1995;26:604–8. [3] Zubair M, Besner G. Pediatric electrical burns: management strategies. Burns 1997;5:413–20. [4] Cunningham PA. The need for cardiac monitoring after electrical injury. Med J Aust 1991;155:765–6. [5] Rabban JT, Blair JA, Rosen CL, Adler JN, Sheridan RL. Mechanism of pediatric electrical injury. Arch Pediatr Adolesc Med 1997;151:696– 700.
Paediatric electrical burn: outlet injury caused by steel chopstick misuse Jong-wook Lee∗ , Young-chul Jang, Suk-joon Oh The Bum Unit, Department of Plastic & Reconstructive Surgery, Hangang Sacred Heart Hospital, Hallym University, Seoul, South Korea Received 9 October 2003; accepted 23 October 2003
Abstract Electrical burn in children in compared with adults is rare due to less chance of exposure to electricity. Although studies have been reported regarding pediatric electrical injury, there are no reports concerning outlet injury, especially those suffered by placing a steel chopstick as conducting material into the wall socket. Steel chopsticks are widely used for eating food in Korea. Children have sometimes injured themselves by inserting these into wall sockets (220 V). A retrospective study was conducted to obtain information about the characteristics of pediatric electrical injury resulting from steel chopstick misuse between January 1996 to June 2002. A total of 57 children with outlet injury were involved. Wounds were multiple and localized within the hand. The prevalent age was about 3 years old. The children studied with low voltage minor electrical injuries were deeply injured, had a high operation rate and remarkable sequelae, although wounds were small and localized. © 2003 Elsevier Ltd and ISBI. All rights reserved. Keywords: Paediatric electrical burn; Steel chopstick
1. Introduction In our hospital, 100 patients are admitted annually with electrical burns. All major electrical accidents occur in the industrial field. Low voltage household injury has been decreased due to product surveillance. However, there is still a problem of electrical outlet injuries. Although there have been some reports about electrical outlet injuries, there has been no reports about pediatric electrical burn suffered by placing a steel chopstick as conducting material into the electrical socket. Chopsticks made of plastic or wood are used for eating food internationally, but steel chopsticks are popular in Korea (Fig. 1). Sometimes children play with these chopsticks that may be easily inserted, due to the long slender shape, into the wall socket (220 V, two pins in our country). The present study was undertaken to identify the characteristics of this electrical outlet injury. 2. Material and methods From January 1996 to June 2002, the records of 63 children with electrical burn who were admitted to our unit were ∗
Corresponding author. Tel.: +82-2-2639-5780; fax: +82-2-2672-9684. E-mail address: [email protected] (J.-w. Lee).
0305-4179/$30.00 © 2003 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2003.10.012
traced. Among them six injured by other etiologies were discarded. A total of 57 children with electrical injury by chopstick misuse were investigated. A retrospective analysis of age and sex distribution, prevalent age and injury site, length of stay, cardiac abnormality, laboratory and electrocardiogram (EKG) data, treatment methods and late outcomes of individual fingers was made.
3. Results Fifty-seven children with electrical outlet injuries were treated at Hangang Sacred Heart Center for Burns and Plastic Surgery over the 6-year Study period. Among them, 33 were male and 24 were female. Their ages were ranged from 1 to 10 years with the commonest occurrence at age 3 (Table 1). There was no abnormality in EKG monitoring, blood chemistry study for creatinine phosphokinase (CPK) level, and urine analysis for myoglobinuria in all patients. All patients injured their hand, other sites were spared. Both hands were involved in 75.4% (Table 2). A total of 202 digits were injured, and burn wounds were multiple and localized (Fig. 2). Total hospital stay was 26 days in average with a mean of 11 days in those conservative treatment and 32 days in those undergoing surgical treatment.
J.-w. Lee et al. / Burns 30 (2004) 244–247
245
Table 1 Age distribution of electrical outlet injuries Age (years)
Number of patients
1 2 3 4 5 6 7 8 9 10
3 8 23 12 3 1 2 2 1 1
Total
57
Fig. 2. Characteristic appearance of chopstick outlet injury. Wounds with severity are multiple and localized within the hand.
Table 3 Treatment methods of injured individual fingers Methods
No. of digits
Conservative Skin graft Local or regional flap Distant flap Island flap Amputation
61 118 3 3 12 5
Total
202
Table 4 Outcomes after treatment Fig. 1. Steel chopsticks for eating food.
Conservative management was used in 16 (28%) out of 57 patients. Forty-one patients underwent operative procedures in 141 digits including STSG, FTSG, local flap, distant flap, island flap, amputation, etc. (Table 3). Among 57 patients, there were post-burn scar contractures in 12 patients, germinal matrix injury in 1, joint angulation deformity in 5 (Fig. 3), growth retardation due to epiphyseal plate injury in 2 (Fig. 4), joint ankylosis in 2, and loss of digit in 5 (Fig. 5) (Table 4).
Table 2 Injury sites of outlet injuries Injury site
No. of patients
Both hands Right hand only Left hand only
43 6 8
Total
57
Percentage (%) 75.4 10.6 14.0 100
Scar contracture Germinal matrix injury Angulation deformity Growth retardation Joint ankylosis Loss of digit
No. of patients
No. of digits
12 1 5 2 2 5
39 1 6 2 2 5
4. Discussion Generally, the resultant damage of electrical burn depends on the type and intensity of current, the tissue resistance, the pathway of flow, and the duration of contact, however, common etiologies of electrical burns in children differ from those of adults. Electrical burns occur typically in poorly supervised or unattended children [1]. These are usually low voltage injuries resulting from placing a metal object into an electrical socket, biting an electrical cord (oral injury), or contacting the low voltage wire or from an appliance. Oral electrical injuries have decreased in recent years while outlet injuries have increased. Although generally Electrical outlet injuries represent less than 15% of all pediatric electrical injuries [1,2], most of our patients had outlet injuries due to the unique culture using steel chopsticks for eating food.
246
J.-w. Lee et al. / Burns 30 (2004) 244–247
Fig. 3. This child had angulation deformity in his right 3, 4 fingers (left). X-ray shows damage close to PIP joint (right).
Most of the patients, especially children with electrical injuries had a justified admission due to the severity of the injury, but admission requirements are controversial for patients who have sustained low voltage injuries [3,4].
There have been reports concerning patients with outlet injury in children with electrical injury [3,5], but there were no children who had sustained an outlet injury by placing steel (metal) chopsticks in the socket. In one study CPK and EKG abnormality were noted in one patient, respectively,
Fig. 4. A child with epiphyseal plate injury in his left middle finger (above). Growth retardation after epiphyseal injury, the right index is small as compared with contralateral finger (below).
J.-w. Lee et al. / Burns 30 (2004) 244–247
247
Fig. 5. The right little finger was mummified due to severe damage (left). Postoperative view after operation (right).
and urine analysis were normal in all [3]. In our series, abnormal findings were not noted in CPK, EKG, and urine analysis. Zubair et al. [3] reported all patients with outlet injuries were treated conservatively without any operative procedure. However, most of our patients had deep second to third degree burn injuries. Forty-one children (72%) among our patients had operative procedures including skin graft and flap surgery due to the severity of the injuries. This demonstrates that greater necrosis occurred in our series in spite of these being low voltage injury. In addition, according to careful follow up after wound healing, specific outcomes close to and involving finger joints were noted. There were angulation deformities and epiphyseal plate injuries due to deep tissue necrosis. Children in our study had a high incidence of outlet injuries in comparison with other studies. The low position of the wall socket, the absence of a blanking plug for socket, and the use of steel chopstick as a conductor. We have advocated high placing of wall socket out of reach of children predispose to these serious injuries an legislation to encourage the use of blanking plugs. Although it can be regarded as
a minor hand burn, the outlet electrical injury resulting from placing steel chopsticks into an electrical socket commonly needs operative procedures. It also can cause cosmetic and functional problems, especially loss of digits, joint angulation, and growth retardation. These types of injuries can be prevented by utilizing simple safety measure together with good supervision of younger children and education concerning electrical hazards in general. References [1] Baker MD, Chiaviello C. Household electrical injuries in children. Epidemiology and identification of avoidable hazards. AJDC 1989;143:59–62. [2] Garcia CT, Smith GA, Cohen DM, Fernandez K. Electrical injuries in a pediatric emergency department. Ann Emerg Med 1995;26:604–8. [3] Zubair M, Besner G. Pediatric electrical burns: management strategies. Burns 1997;5:413–20. [4] Cunningham PA. The need for cardiac monitoring after electrical injury. Med J Aust 1991;155:765–6. [5] Rabban JT, Blair JA, Rosen CL, Adler JN, Sheridan RL. Mechanism of pediatric electrical injury. Arch Pediatr Adolesc Med 1997;151:696– 700.