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Regeneration of full layer necrosis of the skull following high voltage electrical injury
206
Burns (1986) 12,206211
Printed in Great Britain
Regeneration of full layer necrosis of the skull following high voltage electrical injury X. W. Wang, G. J. Miller, E. Bartle, R. Zapata Sirvent, B. B. Roberts and W. A. Robinson Departments of Surgery, Pathology Sciences Center, Denver, Colorado,
and Medicine, USA
University
of Colorado
Health
J. W. L. Davies Department
of Surgery,
Royal Infirmary,
Glasgow,
Scotland
B. G. MacMillan* Shriners
Burns Institute,
Cincinnati,
Ohio, USA
Summary Scalp and skull necrosis often follow high voltage electrical injury to the head. Classically reconstruction of the scalp and skull is performed after sequestration of the necrotic bone. The relatively frequent complication of epidural infection, however, detracts from this approach. As an alternative we have attempted to induce regeneration of devitalized bone by covering it with a vascular tissue flap. A typical patient is described in this report with results which indicate that at least partial regeneration of the necrotic tissue can occur, thus one-stage management of such wounds is possible.
INTRODUCTION A LARGE area of the scalp may become
necrotic when the head is the entrance or exit site for high voltage electricity. The high electrical resistance of the scalp skin and skull bone leads to considerable heat production as the current flows, subsequently leading to necrosis. In contrast the brain tissue is relatively unaffected because of its large volume and extensive vascular network, the electrolytes in which provide a low electrical resistance allowing large amounts of current to flow relatively unimpeded (Worthen, 1971). The classic management of electrical injury of
* Deceased
the skull has been to commence reconstruction after sequestration of the necrotic bone is complete (Dale, 1954; Bagozzi, 1955; Kraugh and Erich, 1961; Jackson, 1975a). Indeed some authors have suggested the drilling of many burr holes through the full thickness of the calvarium to aid the process of sequestration (Artz and Moncrief, 1969; Department of Burns, 1975; Anti-Burn Research Co-ordinating Group, 1977). Due to the longer course of treatment and the relatively frequent occurrence of epidural infection during the period required for sequestration, we have undertaken early removal of the devitalized bone followed by skin flap coverage (Burn Unit, 1973; Wang et al., 1983). This approach has been advocated by Stuckey (1963) and its merits and disadvantages have been discussed by Jackson (1975b). However, both these methods of treatment (either sequestration or immediate removal of all necrotic bone) result in a skull defect which requires subsequent repair using either dead bone or an artificial, possibly plastic, graft. It is now suggested that areas of non-viable bone which are not grossly infected can be preserved by covering them with tissue possessing an adequate blood supply. Such a vascularized flap
Wang et al.: Necrotic skull regeneration obtained by rotation of an adjacent scalp or by anastomosis of a distant tissue flap. We do not remove all the necrotic bone, only the grossly necrotic outer table before coverage with the tissue flap. This technique has been used for the treatment of 24 patients with electrical injuries affecting the skull and provided satisfactory results within a much shorter time spent in hospital. This clinical experience has also shown that this approach is useful in the management of high voltage electrical injury of the humerus (Wang et al., 1980, 1982a,b,c, 1984). At present the fate of the dead bone protected by the skin flap is unknown. Some studies (AntiBurn Research Co-ordinating Group, 1977) have suggested that the dead bone only acts as an inert prop under the protective flap, whereas both Worthen (1971) and Jackson (1975b) believe the flap allows regeneration of the devitalized bone. The detailed histological study of the healing of
burns of the skull in 9 patients by Sevitt (1977) clearly demonstrates the progressive creeping substitution of necrotic bone by new bone in some, but not all, patients with this form of injury. The following patient provides further evidence that regeneration of the presumed dead bone can occur beneath a scalp flap.
Fig. I. Twenty-four of the head wound.
Fig. 2. Thirty-six
can be flap
Fig. 3. Thirty-six
days post-injury.
days post-injury,
The appearance
post-debridement.
CASE REPORT A 29-year-old electrician was injured following hands contact with lOof!G volts ac and head contact with another electric wire. Prior to admission to the Burn Unit 24 days after injury, amputation of the right forearm and excision of eschar on the scalp had been carried out at a local hospital. On admission to our Burn Unit the patient’s injuries included a 13xlScm scalp defect which appeared dark brown in colour (Fig. I) and granulation tissue on the volar aspect of the left wrist and hand. Two days after admission the wound on the volar aspect of the left wrist and hand was debrided. an adjacent skin flap was rotated forward over the wrist
days post-injury,
pre-debridemcnt
Fig. 4. Necrotic bone with virtually no viable osteocytes.
208
Burns (1986)
wound, wound further of the The
and the resulting donor site and left hand were covered with split-thickness skin grafts. A amputation of the right upper arm to the level upper third was also required. exposed skull was debrided 33 days after injury (Fig. 2) using an incision along the normal scalp to remove granulation tissue at the edge of the wound,
Vol.
12/No. 3
thereby exposing a skull defect that then measured 12~ 10.5 cm. Chiselling off the superficial layer of bone indicated a central area of deeper hone (7.5X7cm) which was still brown in colour and surrounded by tissue which showed punctate bleeding (Fig. 3). A small specimen of full layer necrotic hone was removed from the central area for pathological examination. Histopathology indicated necrotic hone with virtually no viable osteocytes (Fig. 4). An adjacent scalp flap (1()X 10.5 cm) was elevated without periosteum and rotated forward over the whole wound (Fig. 5). The flap donor site was covered with a split thickness skin graft (Fig. 6). During the first 5 days after operation blood stained fluid was drained from beneath the flap. Two weeks after the incision had healed, the sutures were removed and the skin Rap in the central area showed complete adhesion (Fig. 7). Follow-up assessment of the patient’s condition for 1 year has indicated no change (Fig. 8). Forty-nine days after injury his left tunica conjunctiva showed vascular congestion with pain, blurred vision and photophobia which was diagnosed as acute iridocyclitis. Appropriate ophthalmological treatment had resolved the inflammation hy Seventeen months after injury flap, indicated by an arrow in Fig. 9) and the condition of the skull
25 days later. the fold in the skin 7, was revised (Fig. was explored. The
c
Fig. S-c. A scalp flap was elevated over the whole debrided wound.
and moved forward
Fig. 6. Two weeks after operation skin which was grafted on the donor scalp flap had taken well.
the split thickness site of the elevated
Wang et al.: Necrotic skull regeneration
Fii’g. 7. One month hcalcd well.
after operation,
209
the scalp flq
has
epicranial aponrurosis of the internal layer adherent to the previously nccrosed skull was peeled off. This now smooth and revealed ;i skull surface that was yellow-white in colour (Fig. 10) without any ohvious periosteum. A small specimen of the full layer of the skull was again taken for pathological examination,
histopathology revealing superficial layers of viable hone in which osteocytcs were present within lacunae. Deeper ;Ispects of the skull still appeared to he nonviable (Fig. I I). During the 17.month interval between the first ;md second operations eight X-ray studies were performed at intervals in an attempt to delineate any change in the depth and extent of bony devitalization. No obvious ch;rnges could be discerned. The patient continues to do well, healing is progressing slowly nnd he has returned to work.
DISCUSSION adds further evidence to support that it is rarely necessary to excise all or even most of the dead bone, particularly from the skull prior to covering the injured area with a tissue Rap. Successful tissue healing over dead bone has been reported by North (1948), and Jackson (1965), Worthen (1971), Trapnell
This
case report
the contention
Lute
and
Hoopes
(lY74)
and
Jackson
(lY7Sb)
even when, as in many of these reports the dead bone contained viable, potentially pathogenic bacteria. No healing failures were attributable to infection. Additionally our histological studies indicting the presence of osteocytes within the lacunae some I7 months after injury support the suggestions made by Worthen (1971), Jackson (lY7Sb) and Sevitt (1977) that dead bone can be gradually replaced by new bone. Clinically these findings are beneficial since early surgical repair without waiting for sequestration of the damaged bone shortens the stay in
F;,q. Xa,h. One year after operation
Burns
210
hospital. A survey of the length of stay in hospital of 24 patients treated by this one stage procedure indicates a reduction of about one half.
(1986)
Vol.
12/No. 3
Acknowledgements The expert typing of Mrs Jean S. Clark is gratefully acknowledged. Dr J. W. L. Davies is financially supported by the United Kingdom Medical Research Council.
REFERENCES
Anti-Burn Research Co-ordinating Group. PLA Third Military Medical College (1977) Therapeutics of Burns. Beijing,
People’s
Medical
Publishing
House,
p. 256.
Fig. 9. Sixteen months after scalp flap cover, the scalp flap was revised.
Fig. 10. The previously
necrosed
the fold in
skull was explored
Fig. 11. Superficial layers of viable bone osteocytes were present within lacunae.
in which
Artz C. P. and Moncrief J. A. (1969) The Treatment of Burns, 2nd ed. Philadelphia: Saunders, p. 157. Bagozzi I. C. (1955) Reparative procedures in large losses of scalp and bone of the skull caused by serious electrical lesions. Br. J. Plust. Surg. 8, 49. Burn Unit, Department of Traumatology and Orthopedics, Peking Jhishueitan Hospital- (1973) Treatment of electrical burns. Analysis on 246 cases. NUI. Med. J. China (Chinese ed.) 53, 253. Dale R. H. (1954) Electrical accidents. Br. J. Plasr. Surg. 7, 44. Department of Burns. Jui Chiu Hospital of Shanghai Second Medical College (1975) Treatment of Burns. Shanghi, Shanghi People’s Publishing House, p. 128. Jackson D. M. (1975a) Burns of bone: can these bones live? 1. Historical review and aetiology. Burns 1,342. Jackson D. M. (1975b) Burns of bone: can these bones live? II. Results of 98 cases and discussion of treatment. Burns 1, 356. Kraugh L. V. and Erich J. B. (1961) Treatment of severe electrical injuries. Am. J. Surg. 101, 419. Lute E. A. and Hoopes J. E. (1974) Electrical burn of the scalp and skull. PIUSI. Reconstr. Surg. 54, 359. North J. P. (1948) Electrical burns of head and arms with residual damage to eyes and brain. Am. J. Surg. 76, 631. Sevitt S. (1977) Healing of burns of the skull: a histological study. Burns 3, 133. Stuckey J. G. (1963) Surgical management of massive electrical burns of the scalp. Plasr. Reconstr. Surg. 32, 538. Trapnell D. H. and Jackson D. M. (1965) Bone and joint changes following burns. C/in. Radial. 16, 180. Wang X. W., Wei J. N., Lu C. S. et al. (1980) Early surgical treatment of severe electrical injury of bilateral upper extremities: a case report. Chin. Surg. J. (Chinese ed.) 18, 573. Wang X. W., Lu C. S., Wei J. N. et al. (1982a) Surgical treatment of high-tension electrically burned upper arms by cutting segmentally necrosed humerus, two case reports. Narl. Med. J. China (Chinese ed.) 62, 556. Wang X. W., Wang N. Z., Lu C. S. et al. (1982b) Early surgical treatment of severe electrical injury of bilateral upper extremities: a case report. Burns 9, 14.
211
Wang et al.: Necrotic skull regeneration
Wang X. W., Wei J. N.. Lu J. Z. et al. (19x2~) Early surgery in severe electrical burns involving upper limbs. Chin. Med. J. 9.5. 717. Wang X. W.. Zhang 0. Z., and Liu H. C. (1983) Treatment of skull burns: analysis of 70 cases. J. Traumu 23, 671. Wang X. W., Lu C. S., Wang N. Z. et al. (1984) High tension electrical burns of upper arms treated by
segmental excision of necrosed humerus: an introduction of a new surgical method. Burns 10. 271. Worthen G. F. (1971) Regeneration of the skull following a deep electrical burn. Plast. Reconstr. Se-g. 48. I.
Paper
accepted
20 November
1985.
(‘“rr~,.\/‘“/~‘l”‘(,~ should hr oddwswd lo: Profcasor X. W. Wang. University of Colorado Health Science\ C‘entcr, Box C302 J21N) t%\t Ninth Avcnuc. Denver. Colorado, X0262. USA.
AMERICAN
BURN ASSOCIATION
Annual
meeting to be held 9-12 April 1986 in Chicago, Illinois
For further information contact Dr Thomas Wachtel Good Samaritan Medical Center 1130 East McDowell Road B-2 Phoenix, Arizona 85006, USA Telephone 602 239 2391
Burns (1986) 12,206211
Printed in Great Britain
Regeneration of full layer necrosis of the skull following high voltage electrical injury X. W. Wang, G. J. Miller, E. Bartle, R. Zapata Sirvent, B. B. Roberts and W. A. Robinson Departments of Surgery, Pathology Sciences Center, Denver, Colorado,
and Medicine, USA
University
of Colorado
Health
J. W. L. Davies Department
of Surgery,
Royal Infirmary,
Glasgow,
Scotland
B. G. MacMillan* Shriners
Burns Institute,
Cincinnati,
Ohio, USA
Summary Scalp and skull necrosis often follow high voltage electrical injury to the head. Classically reconstruction of the scalp and skull is performed after sequestration of the necrotic bone. The relatively frequent complication of epidural infection, however, detracts from this approach. As an alternative we have attempted to induce regeneration of devitalized bone by covering it with a vascular tissue flap. A typical patient is described in this report with results which indicate that at least partial regeneration of the necrotic tissue can occur, thus one-stage management of such wounds is possible.
INTRODUCTION A LARGE area of the scalp may become
necrotic when the head is the entrance or exit site for high voltage electricity. The high electrical resistance of the scalp skin and skull bone leads to considerable heat production as the current flows, subsequently leading to necrosis. In contrast the brain tissue is relatively unaffected because of its large volume and extensive vascular network, the electrolytes in which provide a low electrical resistance allowing large amounts of current to flow relatively unimpeded (Worthen, 1971). The classic management of electrical injury of
* Deceased
the skull has been to commence reconstruction after sequestration of the necrotic bone is complete (Dale, 1954; Bagozzi, 1955; Kraugh and Erich, 1961; Jackson, 1975a). Indeed some authors have suggested the drilling of many burr holes through the full thickness of the calvarium to aid the process of sequestration (Artz and Moncrief, 1969; Department of Burns, 1975; Anti-Burn Research Co-ordinating Group, 1977). Due to the longer course of treatment and the relatively frequent occurrence of epidural infection during the period required for sequestration, we have undertaken early removal of the devitalized bone followed by skin flap coverage (Burn Unit, 1973; Wang et al., 1983). This approach has been advocated by Stuckey (1963) and its merits and disadvantages have been discussed by Jackson (1975b). However, both these methods of treatment (either sequestration or immediate removal of all necrotic bone) result in a skull defect which requires subsequent repair using either dead bone or an artificial, possibly plastic, graft. It is now suggested that areas of non-viable bone which are not grossly infected can be preserved by covering them with tissue possessing an adequate blood supply. Such a vascularized flap
Wang et al.: Necrotic skull regeneration obtained by rotation of an adjacent scalp or by anastomosis of a distant tissue flap. We do not remove all the necrotic bone, only the grossly necrotic outer table before coverage with the tissue flap. This technique has been used for the treatment of 24 patients with electrical injuries affecting the skull and provided satisfactory results within a much shorter time spent in hospital. This clinical experience has also shown that this approach is useful in the management of high voltage electrical injury of the humerus (Wang et al., 1980, 1982a,b,c, 1984). At present the fate of the dead bone protected by the skin flap is unknown. Some studies (AntiBurn Research Co-ordinating Group, 1977) have suggested that the dead bone only acts as an inert prop under the protective flap, whereas both Worthen (1971) and Jackson (1975b) believe the flap allows regeneration of the devitalized bone. The detailed histological study of the healing of
burns of the skull in 9 patients by Sevitt (1977) clearly demonstrates the progressive creeping substitution of necrotic bone by new bone in some, but not all, patients with this form of injury. The following patient provides further evidence that regeneration of the presumed dead bone can occur beneath a scalp flap.
Fig. I. Twenty-four of the head wound.
Fig. 2. Thirty-six
can be flap
Fig. 3. Thirty-six
days post-injury.
days post-injury,
The appearance
post-debridement.
CASE REPORT A 29-year-old electrician was injured following hands contact with lOof!G volts ac and head contact with another electric wire. Prior to admission to the Burn Unit 24 days after injury, amputation of the right forearm and excision of eschar on the scalp had been carried out at a local hospital. On admission to our Burn Unit the patient’s injuries included a 13xlScm scalp defect which appeared dark brown in colour (Fig. I) and granulation tissue on the volar aspect of the left wrist and hand. Two days after admission the wound on the volar aspect of the left wrist and hand was debrided. an adjacent skin flap was rotated forward over the wrist
days post-injury,
pre-debridemcnt
Fig. 4. Necrotic bone with virtually no viable osteocytes.
208
Burns (1986)
wound, wound further of the The
and the resulting donor site and left hand were covered with split-thickness skin grafts. A amputation of the right upper arm to the level upper third was also required. exposed skull was debrided 33 days after injury (Fig. 2) using an incision along the normal scalp to remove granulation tissue at the edge of the wound,
Vol.
12/No. 3
thereby exposing a skull defect that then measured 12~ 10.5 cm. Chiselling off the superficial layer of bone indicated a central area of deeper hone (7.5X7cm) which was still brown in colour and surrounded by tissue which showed punctate bleeding (Fig. 3). A small specimen of full layer necrotic hone was removed from the central area for pathological examination. Histopathology indicated necrotic hone with virtually no viable osteocytes (Fig. 4). An adjacent scalp flap (1()X 10.5 cm) was elevated without periosteum and rotated forward over the whole wound (Fig. 5). The flap donor site was covered with a split thickness skin graft (Fig. 6). During the first 5 days after operation blood stained fluid was drained from beneath the flap. Two weeks after the incision had healed, the sutures were removed and the skin Rap in the central area showed complete adhesion (Fig. 7). Follow-up assessment of the patient’s condition for 1 year has indicated no change (Fig. 8). Forty-nine days after injury his left tunica conjunctiva showed vascular congestion with pain, blurred vision and photophobia which was diagnosed as acute iridocyclitis. Appropriate ophthalmological treatment had resolved the inflammation hy Seventeen months after injury flap, indicated by an arrow in Fig. 9) and the condition of the skull
25 days later. the fold in the skin 7, was revised (Fig. was explored. The
c
Fig. S-c. A scalp flap was elevated over the whole debrided wound.
and moved forward
Fig. 6. Two weeks after operation skin which was grafted on the donor scalp flap had taken well.
the split thickness site of the elevated
Wang et al.: Necrotic skull regeneration
Fii’g. 7. One month hcalcd well.
after operation,
209
the scalp flq
has
epicranial aponrurosis of the internal layer adherent to the previously nccrosed skull was peeled off. This now smooth and revealed ;i skull surface that was yellow-white in colour (Fig. 10) without any ohvious periosteum. A small specimen of the full layer of the skull was again taken for pathological examination,
histopathology revealing superficial layers of viable hone in which osteocytcs were present within lacunae. Deeper ;Ispects of the skull still appeared to he nonviable (Fig. I I). During the 17.month interval between the first ;md second operations eight X-ray studies were performed at intervals in an attempt to delineate any change in the depth and extent of bony devitalization. No obvious ch;rnges could be discerned. The patient continues to do well, healing is progressing slowly nnd he has returned to work.
DISCUSSION adds further evidence to support that it is rarely necessary to excise all or even most of the dead bone, particularly from the skull prior to covering the injured area with a tissue Rap. Successful tissue healing over dead bone has been reported by North (1948), and Jackson (1965), Worthen (1971), Trapnell
This
case report
the contention
Lute
and
Hoopes
(lY74)
and
Jackson
(lY7Sb)
even when, as in many of these reports the dead bone contained viable, potentially pathogenic bacteria. No healing failures were attributable to infection. Additionally our histological studies indicting the presence of osteocytes within the lacunae some I7 months after injury support the suggestions made by Worthen (1971), Jackson (lY7Sb) and Sevitt (1977) that dead bone can be gradually replaced by new bone. Clinically these findings are beneficial since early surgical repair without waiting for sequestration of the damaged bone shortens the stay in
F;,q. Xa,h. One year after operation
Burns
210
hospital. A survey of the length of stay in hospital of 24 patients treated by this one stage procedure indicates a reduction of about one half.
(1986)
Vol.
12/No. 3
Acknowledgements The expert typing of Mrs Jean S. Clark is gratefully acknowledged. Dr J. W. L. Davies is financially supported by the United Kingdom Medical Research Council.
REFERENCES
Anti-Burn Research Co-ordinating Group. PLA Third Military Medical College (1977) Therapeutics of Burns. Beijing,
People’s
Medical
Publishing
House,
p. 256.
Fig. 9. Sixteen months after scalp flap cover, the scalp flap was revised.
Fig. 10. The previously
necrosed
the fold in
skull was explored
Fig. 11. Superficial layers of viable bone osteocytes were present within lacunae.
in which
Artz C. P. and Moncrief J. A. (1969) The Treatment of Burns, 2nd ed. Philadelphia: Saunders, p. 157. Bagozzi I. C. (1955) Reparative procedures in large losses of scalp and bone of the skull caused by serious electrical lesions. Br. J. Plust. Surg. 8, 49. Burn Unit, Department of Traumatology and Orthopedics, Peking Jhishueitan Hospital- (1973) Treatment of electrical burns. Analysis on 246 cases. NUI. Med. J. China (Chinese ed.) 53, 253. Dale R. H. (1954) Electrical accidents. Br. J. Plasr. Surg. 7, 44. Department of Burns. Jui Chiu Hospital of Shanghai Second Medical College (1975) Treatment of Burns. Shanghi, Shanghi People’s Publishing House, p. 128. Jackson D. M. (1975a) Burns of bone: can these bones live? 1. Historical review and aetiology. Burns 1,342. Jackson D. M. (1975b) Burns of bone: can these bones live? II. Results of 98 cases and discussion of treatment. Burns 1, 356. Kraugh L. V. and Erich J. B. (1961) Treatment of severe electrical injuries. Am. J. Surg. 101, 419. Lute E. A. and Hoopes J. E. (1974) Electrical burn of the scalp and skull. PIUSI. Reconstr. Surg. 54, 359. North J. P. (1948) Electrical burns of head and arms with residual damage to eyes and brain. Am. J. Surg. 76, 631. Sevitt S. (1977) Healing of burns of the skull: a histological study. Burns 3, 133. Stuckey J. G. (1963) Surgical management of massive electrical burns of the scalp. Plasr. Reconstr. Surg. 32, 538. Trapnell D. H. and Jackson D. M. (1965) Bone and joint changes following burns. C/in. Radial. 16, 180. Wang X. W., Wei J. N., Lu C. S. et al. (1980) Early surgical treatment of severe electrical injury of bilateral upper extremities: a case report. Chin. Surg. J. (Chinese ed.) 18, 573. Wang X. W., Lu C. S., Wei J. N. et al. (1982a) Surgical treatment of high-tension electrically burned upper arms by cutting segmentally necrosed humerus, two case reports. Narl. Med. J. China (Chinese ed.) 62, 556. Wang X. W., Wang N. Z., Lu C. S. et al. (1982b) Early surgical treatment of severe electrical injury of bilateral upper extremities: a case report. Burns 9, 14.
211
Wang et al.: Necrotic skull regeneration
Wang X. W., Wei J. N.. Lu J. Z. et al. (19x2~) Early surgery in severe electrical burns involving upper limbs. Chin. Med. J. 9.5. 717. Wang X. W.. Zhang 0. Z., and Liu H. C. (1983) Treatment of skull burns: analysis of 70 cases. J. Traumu 23, 671. Wang X. W., Lu C. S., Wang N. Z. et al. (1984) High tension electrical burns of upper arms treated by
segmental excision of necrosed humerus: an introduction of a new surgical method. Burns 10. 271. Worthen G. F. (1971) Regeneration of the skull following a deep electrical burn. Plast. Reconstr. Se-g. 48. I.
Paper
accepted
20 November
1985.
(‘“rr~,.\/‘“/~‘l”‘(,~ should hr oddwswd lo: Profcasor X. W. Wang. University of Colorado Health Science\ C‘entcr, Box C302 J21N) t%\t Ninth Avcnuc. Denver. Colorado, X0262. USA.
AMERICAN
BURN ASSOCIATION
Annual
meeting to be held 9-12 April 1986 in Chicago, Illinois
For further information contact Dr Thomas Wachtel Good Samaritan Medical Center 1130 East McDowell Road B-2 Phoenix, Arizona 85006, USA Telephone 602 239 2391