Y. Kaloudová; H. Řihová; P. Brychta; I. Suchánek; J. Kučera; I. Menšík; H. Krupicová; B. Lipový
Department of Burns and Reconstruction Surgery, University Hospital, Brno, Czech Republic
Vyšlo v časopise:
ACTA CHIRURGIAE PLASTICAE, 50, 1, 2008, pp. 11-15
passage of aĘhigh-voltage electrical current through aĘhuman body
causes depolarization of the cell membranes with aĘwide variety of
possible consequences that can even lead to the destruction of these
cells. At the same time electric energy is transformed to thermal
energy in the tissues involved, mainly in high resistance tissues
(1). Progression of the necrosis is characteristic of electrotrauma
(1). To maintain vitality of the peripheral parts of extremities it
is very important to prevent compartment syndrome. This can be
achieved by repeated very careful examination, evaluation of the
status and earliest possible completion of releasing cuts of the skin
and into subcutis after aĘcircular deep burn; however, first of all
come fasciotomies of all muscle groups in the impaired extremity.
After electric current passes through the extremities, subescharotic
and subfascial oedema develops (1). The most important task is to
release deep paraosseal muscle groups. Fasciotomy must be completed
within 6Đ8 hours after the injury at the latest (1, 2). When
high-voltage electrical current passes through the extremity, often
skin and subcutis appear intact; however, muscle structures are
damaged. Electrotrauma leads to pathological changes due to the
thermal effect and also to the developing oedema of tissues. The
oedema quickly increases during the first eight hours after the
injury and then gradually increases until 24 hours after the injury
(1). Fasciotomy allows the release of overpressure in particular
muscle groups, and blood supply in the extremity improves (1, 2).
the Czech Republic the main electric grid has a voltage of 230 V, 22
kV, 110 kV, 220 kV, 400 kV.
the electrified railway lines the voltage between the trolley and the
rail is 3000 VĘ(direct current in the northern part of the Czech
Republic) or 25 kV (alternating current in southern Czech Republic).
the trolley of a Prague tram and the rail the voltage is 600 V, the
same as between the wires for trolleybus. Between the rail and
current collecting rail (“third rail”) in the metro the voltage
is 750 V(4).
2005, Lipnice nad Sázavou. Assembling work on the high-voltage
overhead line tower (22 kV). The current in the wires is turned off,
and a fitter works tied to the line tower with safety belts.
01:30 PM the current in the line is revived and the
22-year-old man is hit by an electrical discharge. Unconsciousness,
tonic clonic convulsions. After the electrical current is turned off
the stricken man is untied from the belts and transported to the
ground by the elevating platform. On arrival of an ambulance the man
ventilates spontaneously, is conscious, has retrograde amnesia, heart
beat is regular, pulse is 110 beats per minute, blood pressure is
adequate transfer by Air Ambulance
to our Department of Burns and Reconstruction Surgery in Brno,
admission at 02.50 PM.
Petechiae in face and in
the lumbar area, small injuries to the tongue.
Flexion contracture of
the left upper extremity in the elbow joint, full fixated extension
in the left radiocarpal joint.
Deep burns in the left
axilla, deep circular burns on arm and forearm left, noncircular
burns of fingers and palm of the left hand.
Flexion position in the
radiocarpal joint of the right upper extremity, fingers in full
flexion, deep burns of the right palm and fingers, oedema of the
right wrist and distal part of the forearm.
Right foot in equinovarus
position, circular deep burns of distal half of the right shank and
Total extent of the deep
burned areas was 10% of the body surface. Clear clinical and
laboratory signs of passage of the electrical current through the
patient are present.
examination at the surgery in general anesthesia – immediately
Escharotomy axilla Đ arm
Đ forearm Đ hand.
Fasciotomy on arm,
forearm and flexor retinaculotomy (already apparent necroses of
biceps brachii muscle, brachioradialis, triceps brachii tenton,
necrosis of olecranon and head of radius, necrosis of the proximal
portions of extensors at the forearm).
Elbow contracture release
as well as the radiocarpal joint.
Excision of the necrotic
skin and subcutis in the left cubita and at the dorsal part of
Right upper extremity:
Escharotomy of the
forearm, wrist and hand.
Fasciotomy of the
anterior muscle group and deep muscle groups of the forearm.
(right median nerve necrotic).
Right lower extremity:
Escharotomy shank -
Fasciotomy on shank
(apparent are necroses of anterior and deep muscle groups of the
day after the injury – revision in general anesthesia
Massive oedema in subcutis
and subfascia on upper extremities and on the right lower extremity.
Excision of clearly
bordered necrosis of the skin and subcutis in right forearm and right
Fasciotomy extended to
thorax - release of pectoralis major muscle.
day after the injury
Amputation of the right
lower extremity in shank (ischemic necrosis of the distal third of
shank and foot). Stumps of fibula and tibia covered by a dorsal
muscle flap from the intact calf muscles.
Eighth day after the injury
Amputationof the left upper
extremity below the shoulder (necrotic colliquating muscle groups
distally on arm and forearm, necrotic ulna and radius in proximal two
thirds and necrosis of the humerus in distal one third). The humeral
stump covered by vital muscle remainders of arm and the adaptation
suture for rotation of laterodorsal skin and subcutaneous flaps.
day after the injury
Exarticulation of left
upper extremity in the shoulder (humerus completely necrotic,
progression of necrosis to the humeral stump muscles). Vital part of
deltoid muscle was rotated into the defect after exarticulation,
adaptation suture of deltoid muscle fascia and latissimus dorsi,
defect covered by rotation of the dorsolateral fasciocutaneous flap
from the arm.
Eighteenth day after the injury
Autografting of the stump
apex of the right shank with split-thickness grafts.
Twenty-eighth to thirty-eighth day after the injury
Repeated dressing changes
at the intensive care unit (analgesia and deep sedation),
Forty-fifth day after the injury
Excision of the bordered
necrosis of the right median nerve.
Microsurgery transfer of
the right parascapular fasciocutaneous flap to the distal part of the
right forearm, wrist and thenar for the soft tissues defect closure.
Surgery was completed by
microsurgery team of our workplace.
Two and half months after the injury
Patient discharged home.
Outpatient care, physical
and psychological rehabilitation followed.
Four months after the injury
Reconstruction of the
right median nerve in the area of distal forearm and wrist Đ nerve
graft from the left suralis nerve, length 12 cm.
One and a half years after the injury
Reconstruction of the
right thumb long flexor tendon with aĘtendon graft from the left
Two years after the injury
Function of the right
hand in terms of grip is satisfactory (he was able to complete pinch
grip and sign). Gait on the right prosthesis was very good.
measurement of the pressure in the intracompartment space is not
possible in extensive burns due to open wounds, either from burns or
wounds after fasciotomy. Intrafascial pressure can be validly
measured only after removal of dressings which cover extensive wounds - in our case this could have been achieved only in the operating
room. Moreover, in the intensive care this practice would in many
cases be in conflict with the hygienic/epidemiology regime. Therefore
every half an hour for the first eight hours after the injury
experienced burn specialists completed a palpation examination of
the muscle groups - even over the dressings (1). It is recommended
that the examination is performed by one experienced person who
palpates the increasing tension of muscle groups. If the finding is
positive, immediate revision of the patient’s wounds in the
operating room is necessary, and usually further fasciotomies at the
impaired extremity must be completed. We have to be aware that often
the compartment syndrome develops in deep periosseal muscle groups
and deep nerve and blood vessel bundles frequently under intact
skin and subcutis. Weakened pulsation of arteries at the
periphery of extremities is a late symptom of already irreversible
damage to the deep structures.
escharotomies of the skin and subcutis and fasciotomies at the
impaired extremities that show signs of passage of the high voltage
electric current (areas of contacts, i.e. exits or entrances of the
electric current) must be completed in the full length of the
extremity and tied together in the axilla to the fascias of chest
treatment of the burn shock obviously helps the blood circulation in
extremities and helps to maintain as many structures as possible
maximize the vitality of tissues at the extremities the authors
stress the importance of earliest fasciotomies of the impaired
extremities. After the passage of a high-voltage electrical current
through an extremity it is necessary to release all muscle groups,
especially the paraosseal, eight hours after the injury at the very
latest. Evaluation of the clinical status in the first 24 hours after
the injury should be assigned to the most experienced burn specialist