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High-voltage electrical injury usually causes severe tissue damage and serious secondary complications. We report a case of treatment of severe high-voltage electrical injury. A series of personalized and effective treatment plans were created through repeated discussions, we successfully handled a series of acute and critical conditions, including severe limb damage, a very large area of full-thickness abdominal wall defect, abdominal viscera (stomach and liver) necrosis, abdominal infection, renal insufficiency, myocardial damage, and malignant arrhythmia (atrial fibrillation). Finally, the wounds were all closed, the functions of the abdominal organs were restored, and the course of the disease was successfully transitioned into the rehabilitation stage. It took a lot of twists and turns but ultimately saved the patient's life. The successful treatment of this patient provides an important reference for similar patients with serious electrical injury in the future., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Electrical burns pose unique challenges in reconstructive surgery due to the extensive tissue damage they cause. The thumb is particularly susceptible to electrical burns, leading to severe functional impairment. This case series introduces the use of the temporal fascia free flap for thumb coverage in patients with electrical burn injuries. The study aims to assess the functional outcomes of this approach using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Six male patients underwent thumb reconstruction using temporal fascia free flaps following electrical burn injuries. The extent of the injury was assessed, and necrotic tissue was debrided. Functional outcomes were evaluated using the DASH questionnaire 6 months postoperation. All procedures were conducted in accordance with ethical guidelines, and informed consent was obtained from all patients. All patients achieved successful transplants using temporal fascia free flaps. The average DASH score at the 6-month follow-up indicated satisfactory functional recovery. Patients reported improvements in thumb mobility and functionality, and the cosmetic appearance of the thumb was acceptable. The appearance of the scar in the donor area was well-received. The temporal fascia free flap proved to be an effective method for thumb reconstruction following electrical burn injuries. Its thin and flexible nature allows for optimal contouring and improved range of motion. Although one case of partial flap loss was observed, overall functional and aesthetic outcomes were satisfactory. Further research with larger sample sizes is warranted to optimize surgical techniques and postoperative care for better outcomes., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Advancements in technology allow for the utilization of low-voltage battery-powered devices for patients admitted to the hospital. There have been rare cases of burns due to leakage of the internal contents from low-voltage batteries, but to date, there have been no reports of electrical burns caused by low-voltage batteries. We present the case of an 89-year-old female who presented to the general surgery service with a suspected electrical burn from laying on a 9-volt battery. The patient underwent operative debridement with no evidence of a deeper injury. The patient continues to follow up with an outpatient wound clinic and is healing well. This case highlights the importance of teaching and raising awareness of all small devices that may become entangled or lost in patients' linens, such as 9-volt telemetry batteries, to prevent harm., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Type III electrical burns on the wrist are characterized by circumferential wounds, three dimensional with sandwich-like necrosis, and progressive blood circulation disturbances. Limb salvage is challenging, and success in meeting this challenge depends on vascular reconstruction and wound coverage. This article is intended for the following purposes: to investigate the principles of wound debridement, the management of involved blood vessels, and the clinical effects of the extended paraumbilical perforator flap pedicled with the inferior epigastric artery for coverage of type III circumferential electrical burns of the wrist. A total of 13 male patients (age, 20 to 43 years; average, 29 years) were enrolled in the study. After early escharotomy, debridement, and vascular reconstruction, all wounds were repaired with the extended paraumbilical perforator flap pedicled with the inferior epigastric artery. Flap survival was achieved in all 13 patients. Subcutaneous liquefaction necrosis and infection beneath the flap occurred in three patients. Radial or ulnar artery reconstruction via the great saphenous vein (GSV) graft was performed in 12 cases. All patients had a mean follow-up of 6 to 36 months, and the flaps demonstrated satisfactory flexibility and texture. Hand function was preserved in eight patients, and no patients developed abdominal hernia. Thorough debridement, early vascular reestablishment, and wound coverage are essential for the overall limb salvage effort for type III circumferential electrical burns of the wrist. The extended paraumbilical perforator flap may provide a new and appropriate option for the primary repair of extensive soft tissue defects., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Soft tissue damage in electric burn injuries is often deep and may expose tendons, bones, or joints in the hand. Here, we present the case of a 76-year-old man treated using perifascial areolar tissue (PAT) transplantation for covering the proximal interphalangeal joint of the middle finger, which had been exposed because of an electric burn. Following ointment therapy, surgery was performed on day 34 postinjury when a deep ulcer with opening of the proximal interphalangeal joint was observed on the dorsum of the right middle finger. After resecting the cartilage of the proximal interphalangeal articular surface, two Kirschner wires were inserted, and arthrodesis was performed. PAT was harvested from the left inguinal region and applied to the joint exposed wound of the middle finger. Full-thickness skin graft was applied over it. Three months after surgery, the preserved middle finger could be used as a functional finger. PAT transplantation does not require microsurgery techniques, is simple and minimally invasive, and has a short treatment period, so it may be an effective option for treating wounds in which exposed ischemic tissue is present. Soft tissue damage in electric burn injuries is often deep and may expose tendons, bones, and joints in the hand, which is the most common affected site. Here, we report a case treated using perifascial areolar tissue (PAT) transplantation for covering the proximal interphalangeal joint of the middle finger, which had been exposed because of an electric burn., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Electrical trauma is associated with significant morbidity and mortality, which have been reduced by improved medical care, as measured by the length of stay (LOS) as a marker for this population's quality of care. This paper will review the clinical and demographic characteristics, LOS in the hospital, and variables related to patients with electrical burns. A retrospective cohort study was conducted at a specialized burn unit in Southwest Colombia. Five hundred seventy-five electrical burn-related admissions from 2000 to 2016 were reviewed for the LOS and variables including patient-related (age, gender, marital status, education, and occupation), location of the accident (domestic vs labor-related), voltage, direct contact, arc, flash, flame, clinical presentation (burn surface area, depth, single or multiple organ injury, secondary infection, and abnormal labs), and treatment (surgical procedures and intensive care unit [ICU] admission). Univariate and bivariate analysis, with its 95% CI (confidence interval). We also performed a multiple logistic regression. LOS was correlated to males, age greater than 20 years, construction workers, high voltage injuries, severe burns by area and depth, infection, ICU admission, and multiple surgical procedures or extremity amputation. LOS due to electrical injury was observed to be significantly associated with the following variables, carpal tunnel release (OR [odds ratio]= 4.25, 95% CI [confidence interval] 1.70-5.20); amputation (OR = 2.81, 95% CI 1.60-5.10); infection (OR = 2.60, 95% CI 1.30-5.20); site of infection, mainly wound (OR = 1.30, 95% CI 1.10-1.44); associated injury (OR = 1.72, 95% CI 1.00-3.24); work or domestic accident (OR = 1.83, 95% CI 1.00-3.32); aged 20-40 years (OR = 1.41, 95% CI 1.00-2.10); CPK (OR = 1.40, 95% CI 1.00-2.00); and third-degree burns (OR = 1.55, 95% CI 1.00-2.80). Risk factors for LOS secondary to electrical injury should be appropriately addressed. Prevention at high-risk workplaces is imperative. Mitigating the injury with appropriate management of infection and timely surgical interventions play an essential role in the successful treatment of these patients., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

While high-voltage electrical injuries usually cause severe burn wounds and axonal polyneuropathy, low-voltage electrical injuries cause limited cutaneous wounds and demyelinating mononeuropathy, of which the median and ulnar nerves are the most commonly involved. We present the case of a 42-year-old man who suffered a 480-voltage electrical injury at his right elbow, resulting in a 24 × 10 cm fourth-degree burn wound and immediate radial nerve palsy. The burn wound was debrided with confirmation and preservation of radial nerve continuity. The wound was covered with a free anterolateral thigh flap and it healed uneventfully. The Tinel's sign continued to advance at follow-up, and electrodiagnostic studies showed progressive reinnervation. His radial nerve function recovered completely in 9 months. This is a rare case of low-voltage electrical injury with a fourth-degree burn wound and immediate radial nerve palsy. We treated the wound aggressively with early debridement and prompt flap coverage, but conservatively treated the radial nerve injury. The nerve recovery course indicates that it had a "shocked-cooked" injury and served itself as a well-placed nerve graft for the subsequent regeneration. We believe that our successful outcome in this case can provide more insights into the management of such injuries., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

High-voltage electrical injury is a rare yet destructive class of burn injury that persists as a serious public health issue. High-voltage exposure is commonly associated with complex wounds to the upper extremities, which can be a significant challenge for burn and plastic surgeons to reconstruct. This intensive and multistage reconstructive process is especially difficult in the growing child. Maximizing upper extremity function is a top priority, as it can have a significant impact on a patient's quality of life. Therefore, the purpose of this retrospective review was to describe lessons learned during a 13-year experience at a specialized pediatric burn hospital with reconstruction of the upper extremity after severe high-voltage injury in 37 children. We found that adherence to the following principles can help promote meaningful functional recovery. These include 1) frequent assessment during early acute care for the evolving need of decompression or amputation; 2) serial surgical debridement that follows a tissue-sparing technique; 3) wound closure by skin grafting or use of flaps (particularly groin or abdominal pedicled flaps) when deep musculoskeletal structures are involved; 4) early multidisciplinary intervention for contracture prevention and management, including physical and occupational therapy, splinting, and fixation; 5) reconstructive care that focuses on the simplest possible techniques to repair chronic skin defects such as laser therapy, local tissue rearrangements, and skin grafting; 6) complex reconstruction to address deeper tissue contractures or tendon and peripheral nerve deficits; and 7) amputation with preservation of growth plates, tissue transfer, and long-term prosthetic management when limb salvage is unlikely., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Severe IV-degree thermal crush injury of limbs involved the subcutaneous fascia, muscle and bone, which may lead to amputation and has a great impact on the patient's quality of life. We can repair wounds with pedicle flaps or even free flaps, However, there are still huge challenges in bone defect of extremities and functional reconstruction. In recent years, with the development of functional prostheses, we have reconstructed limb functions in many patients helping them to complete their daily lives. We report a case where the right upper arm was injured by thermal crush, leading severe burns to the skin, fascia, muscle and bone. We applied a pedicled latissimus dorsi flap and a free anterolateral thigh flap to repair the wound, and realized the function of limb salvage and movement of the right upper arm by implanting 3D printed scapula, upper arm, and elbow joint prostheses. This case illustrates that IV-degree burns involving bones have new technologies to repair and achieve mobility now., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Fasciotomy is indicated to relieve compartment syndrome caused by electric burns. Many techniques are available to close the fasciotomy wounds including vacuum-assisted closure, skin grafting, and healing by secondary intention. This study assessed the shoelace technique in fasciotomy wound closure in patients with electric burns. The study included 19 fasciotomy wounds that were treated by shoelace technique (Group ST, n = 10 fasciotomy wounds) or by skin grafting/healing by secondary intention (Group C, n = 9 fasciotomy wounds). Data were collected for wound surface area, time to intervention, time to wound closure, rate of decrease in wound surface area after application of shoelace technique and associated complications. The mean time to intervention after fasciotomy was significantly lower in Group ST-7.6 ± 3.8 days as compared to 15.8 ± 5.3 days in Group C (P = .004). The median time to closure was also significantly lower in Group ST-7 days (range 6-10) as compared to Group C-20 days (range 12-48) (P < .001). Primary closure was achieved in 80% cases in the group ST and no complications were recorded. The shoelace technique is an economical, fast, and effective method of fasciotomy wound closure in electric burns, especially in high volume centers and resource-limited areas., (© The Author(s) 2020. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The art of pyrography, burning designs in wood, dates back to prehistory. Risks of traditional techniques included cutaneous burns and airway injury. Fractal wood burning is a niche technique using a high-voltage electrical source to burn branched designs into wood. While this technique has grown in popularity, the associated risks are not well understood. We describe a patient who presented to our burn center after sustaining high-voltage electrical injuries while making fractal wood art using an improvised a high-voltage transformer. During the wood-burning process, he contacted the electrodes and suffered full-thickness electrical burns to the neck, chest, and bilateral upper extremities. Bilateral upper extremity fasciotomies were performed on admission. Multiple subsequent operations culminated with autografting to most of the wounds and complex reconstruction of the left thumb. In evaluating online news reports, we found 25 unique individuals with death or injury attributed to fractal wood burning from July 2016 to January 2020. Five sustained substantial injuries, while 20 reportedly died. Ages ranged from 17 years old to the 60s. One death and one injury occurred in females, with the remainder of reports involving males. Of the survivors, four sustained significant upper extremity electrical injuries and three suffered cardiac arrest at the time of injury. Fractal wood burning is associated with devastating high-voltage electrical injuries and death. Prevention efforts should be focused on education about the potential for death and permanently disabling injuries from this art form., (© The Author(s) 2020. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Electrical burn injuries are one of the most severe forms of trauma. This study aims to investigate the infection complications in electrical burn patients in a referral hospital in Mexico City. A longitudinal retrospective study was conducted, involving electrical burn patients admitted from April 2011 to December 2016. Demographic and clinical data including type of electric burns, infection complications, and mortality was sought. Data were collected at admission and daily until discharge. Number and type of infections and microorganism isolations were sought. Risk factors for death were analyzed. A total of 111 patients were included, of which 96.4% were males, mean age of 31.6±16.22, most injuries were high voltage associated. The total body surface area average was 27.8% ± 19.63. The overall infection rate was 72.9 cases per 100 patients. Mortality was observed in 4 (3.6%) patients. About 59.1% (443/749) had growth for Gram-negative bacteria. Multidrug-resistant Pseudomonas aeruginosa was the most frequent microorganism isolated. Fungi were present in 4.9% of cases. Electrical burn injuries occurred in young males in our study. Infection was frequent, most of them caused by Gram-negative rods with an important rate of antimicrobial resistance; however, an important microbial diversity was present., (© American Burn Association 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

In a patient with a high-voltage electrical burns, the extent of burning is greatest at the entrance and exit points of the electric current. As the exit point is usually the ankle and/or foot, these areas may be the most severely damaged. As local tissue is limited in this region, free tissue transfer is usually required for reconstruction. Eleven anterolateral thigh free flaps were placed for the reconstruction of foot and ankle defects caused by electrical burns. When the defects were large, we placed the flaps with two or three perforators. In six patients, recipient vessels were prepared in the trauma region or immediately adjacent thereto. Reconstructions were performed at an average of 23.18 days after the burns, and the average hospitalization time was 42.27 days. Patients with burns on the dorsum of the foot often required toe amputations. In patients who underwent direct reconstruction (without debridement), re-operations were required because of graft loss in other burnt areas. The foot and ankle are the regions most damaged by electrical burns. Vessels in the trauma zone or immediately proximal thereto can serve as recipient vessels. Even when the defect is sizeable, a large anterolateral thigh flap with multiple perforators can be harvested. No vascular problem was encountered during early or late reconstruction. The free flap is very reliable when used to reconstruct foot tissue defects caused by electrical burns., (© American Burn Association 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Repairing soft tissue defects of the forehead which exposes the bare bone is a dilemma with few reconstructive techniques for plastic surgeons. Forehead is an important aesthetic unit of the face which is covered with the glabrous skin. Due to the relative lack of similar mobile tissue locally, reconstruction of large soft tissue defects of the forehead region by local flaps is demanding. Temporalis muscle flap does not reach to the midline of the forehead region because of the insufficient length of the deep temporal vascular system. During the transfer of the muscle, only a small volume and size of the muscle can reach to the defect, remaining most of the muscle bulk in the pedicle and a relatively limited arc of rotation, thus a small volume of usable tissue at the distal portion of the flap. We successfully used reverse flow temporalis muscle flap for the purpose of eliminating the above-mentioned disadvantage of temporalis muscle flap in a 23-year-old male patient who sustained a high-voltage electrical burn resulting 12 × 8 cm left forehead defect exposing the bare bone., (© American Burn Association 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

This study aimed to introduce a novel technique for reconstructing electricity-damaged fingers using a method combining the free vascularized anterolateral thigh fascia lata flap with skin grafting. From February 2015 to March 2017, 11 patients were enrolled in this retrospective case series. All patients suffered from electrical injury of the fingers and had severe soft tissue defects, with the exposure of tendon, vessels, or nerves. All finger wounds were covered using free vascularized anterolateral thigh fascia lata flaps combined with skin grafting. Eleven fascia flaps completely survived. Two patients suffered from partial grafting skin necrosis due to wound infection and subcutaneous hematoma, separately, which eventually healed after re-graft and dressing changes. All patients achieved satisfactory function and appearance without a need for repeated grafting. Except for the scar, no donor-site morbidity was reported. The present study provided an attractive option for treating electricity-damaged fingers with good outcomes and minimal donor-site morbidity., (© The Author(s) 2019. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Electrical injuries induce substantial morbidity and mortality. Amputations are often necessary to enable survival and based on tissue nonviability, development of life-threatening infection, or expected nonfunctional outcome. They analyzed occurrence and type of amputations in their institution for electrical and nonelectrical pediatric burns and the number of reconstructive operations. Patients who underwent any amputation between 1999 and 2017 were identified. Patients with electrical burns (EB) were matched regarding age, sex, and percent total body surface area (%TBSA) burned to patients with nonelectrical burns (NEB). Both groups (n = 35 EB, n = 70 NEB) were comparable regarding age (EB, 11.6 ± 4.5 years; NEB, 11.1 ± 4.5 years, P = .550) and %TBSA (36.7 ± 15.4% and 37.7 ± 12.9%, P = .738). Major amputations (above wrist or ankle) were performed in 77% of EB vs 31% of NEB (P < .001). Amputations above knee or elbow were performed in 13 (37.1%) vs two patients (2.9%, P < .001). Eight (22.9%) vs six patients (8.6%) underwent combination of two or more major amputations (P = .042). In both groups, most amputations were performed for functional reasons. Length of stay was shorter in EB group (33 ± 27 vs 47 ± 38 days, P = .040). EB patients underwent 9.9 ± 7.1 total operations compared with 14.4 ± 5.1 operations (P < .001). Of these, 6.5 ± 3.6 and 7.9 ± 3.3 (P = .023) were performed during acute stay and 3.3 ± 4.8 and 6.5 ± 3.5 after acute stay (P < .001), respectively. Mortality was comparable. EB were associated with larger extent of limb loss and more major amputations than NEB with amputations. They furthermore required a smaller number of reconstructive procedures. EB require extra attention of caregivers, because of their extensive tissue damage.

Severe electrical injury presents a formidable therapeutic challenge for surgeons because of the requirement for complex soft tissue and bony reconstruction to restore functionality of the injured area. The authors report on the limb salvage procedure for a patient with extensive soft tissue and femoral bone necrosis from a high-voltage electrical burn. The right thigh and knee were burned, resulting in large areas of muscle necrosis and a long segment of distal femur exposure and necrosis. Complete debridement of the area resulted in a 20 × 35 cm soft tissue defect and an 18-cm long distal femoral bone defect. The wound was repaired through latissimus dorsi muscle transplantation and bony reconstruction using the sequential Ilizarov osteogenesis method. The injured limb was retained, and the functional recovery of the patient's leg was satisfactory. This experience indicates that the combination of flap transplantation and the Ilizarov osteogenesis method are good options for the treatment of large soft tissue and huge segmental bony defects.

Electrical burns are responsible for arterial and venous thrombosis, as well as weakening of the arteries. Immediate or delayed arterial occlusions, secondary to the aggression of the intima, or aneurysms, secondary to the aggression of the media, sometimes lead to artery ruptures without any warning signs. Such ruptures may trigger a hemorrhagic shock whose period of onset is variable and unpredictable. We are presenting here three cases treated in our department for electrical burns, whose complications were marked by hemorrhagic shock, secondary to late artery ruptures, sometimes occurring several months following the event. These case reports required performance of emergency hemostasis in order to control sudden bleeding, with first approach being placement of a tourniquet at the base of the limb and/or a compression point. Through these cases, we thought it is crucial to closely monitor for a few weeks all patients who were victims of electrical injury, even more so if it was associated with a compartment syndrome of one or more limbs and high rhabdomyolysis, which seem to be predictive factors of late artery ruptures in our case reports.

Some groups have avoided early microsurgical flaps in electrical burns under the pretext of injury to the microvasculature, which could increase vascular thrombosis. However, this option frequently results in amputation of the extremity. This study aims to evaluate the early application of microsurgical flaps for the treatment of electrical burns of extremities. A case series was retrospectively evaluated including patients with electrical trauma in extremities undergoing early microsurgical reconstruction. Data were obtained from medical charts, including age, trauma location, flap type and microvascular anastomosis, the need for other procedures, postoperative complications, the length of hospital stay after the flap surgery, and patient outcomes. Five microsurgical flaps were performed in less than 30 days to trauma, one anterolateral thigh flap to cover skin failure in upper limb, and four radial forearm flaps to cover failure in feet. The patient ages had a mean of 25.8 years (from 12 to 42 years). The microsurgical procedure occurred from 21 to 27 days after the burn, with a mean of 24.2 days. Hospital discharge had a mean of 26.6 days (from 19 to 35 days after the surgery). Only one patient required reintervention for re-anastomosis. All patients had a good flap viability, avoiding amputation of the affected extremity and with a proper preservation of function. The early application of microsurgical flaps for patients with electrical burns of extremities may provide adequate, sturdy, and stable skin coverage, contributing to the treatment of noble structures exposed and avoiding amputation of the extremities.

The objective of this study was to report the case and multidisciplinary management of a 44-year-old man with 40% TBSA third- and fourth-degree burns sustained during high-voltage electrical injury including 3 limb amputation and bowel necrosis requiring small bowel resection. This study is a case report and review of the literature. A 44-year-old man was brought to the Emergency Department with 40% TBSA third- and fourth-degree burns sustained during accidental contact with high-voltage electric current. He had multisystem injury including injuries to 3 of his extremities ultimately requiring a forequarter amputation of the left upper extremity and guillotine amputations of his bilateral lower extremities. He also sustained a visceral injury and underwent small bowel resection. While amputations are very common in electrical burn injuries, visceral electrical injuries are not. High-voltage electrical injuries are devastating multisystem insults that require multidisciplinary critical and operative care.

Patients with high-voltage electrical injuries had very high rates of infection, morbidity, and limb amputation. The results of early and late flap coverage in these patients were prospectively compared. The patients were divided into two groups, early flap group (≤3 weeks) and late flap group (>3 weeks), according to the length of time from injury to wound coverage with flap. Age, sex, demographic data, time taken for flap coverage, time taken for pedicle division, time taken to discharge, wound infection, range of motion in joints, amputation, mortality, and outcome were gathered in a special questionnaire. This study included 55 patients, 31 within the early flap group and 24 within the late flap group. Of the 55 patients, 94.6% were male; mean (SD) of age was 29.04 (10.11) and of TBSA was 13.8 (10.07). Length of stay was significantly longer in the late flap group. The rates of infection and amputation were lower in the early flap group. There was no correlation between the type and the number of flaps and amputations. Early flap repair reduces the length of stay by 56%, rate of amputation by 54%, and also 86.1% in the rate of infection in the burn site.

The authors report the case of a 30-year-old male with 52% TBSA high-voltage electrical injury of the upper half of the body. Injuries included a cervical burn with associated alteration of the left brachial plexus as well as extensive soft tissue burn of the right hand. Three months later, he developed osteomyelitis of the right thumb metacarpal bone requiring amputation proximal to the metacarpophalangeal joint. Following initial management, the patient had a permanent distal left upper extremity paralysis with nonfunctional but relatively undamaged ipsilateral hand digits. The right hand remained functional with four intact digits and a thumb stump. Usually, late reconstruction of proximal thumb amputation is performed by pollicization or free toe transfer procedures. In this particular case, right thumb reconstruction was done by free transfer of the left little finger. Four months postoperatively, the patient demonstrated a functional pinch between the reconstructed thumb and the ipsilateral digits along with improving sensation. This uncommon surgical procedure restored a functional thumb with minimal donor site morbidity. The decision-making process and operative technique are presented in detail along with a review of the thumb reconstruction literature.

Electrical burns can be devastating and result in dreaded outcomes. Electrical burn is a common problem in our society and needs special attention because of its various modes of presentations, the numbers of organ systems involved, and the mortality associated in spite of the small percent of burns. The authors present a case of electrical burns with a posterolateral chest wall defect associated with blunt abdominal trauma that was successfully managed by debridement and pedicled omental flap over a synthetic prolene mesh.

High-voltage electrical burns on genitalia and perineal areas are very rare and only sporadic reports are available in the literature with often confusing diagnoses and inconspicuous treatment protocols. Although the surgical treatment of extremities lesions is well established and includes appropriate debridement, temporary wounds coverage, and final adequate soft-tissue reconstruction, management of genital lesions remains controversial and challenging. The authors present a rare case of severe high-voltage electrical injury with involvement of upper extremities and complex lesions localized to the genitalia and perineal region. Treatment required a multidisciplinary approach including the plastic surgery and the urologic and andrologic teams.

Severe burns result in a profound hypermetabolic response. Catecholaminergic surges secondary to the burn injury itself, particularly if superimposed on premorbid cardiac disease, can result in cardiac arrhythmias. If unstable, these cardiac rhythm disturbances necessitate immediate cardioversion to regain normal sinus rhythm. Because of the high impedance at the skin-paddle interface, superficial cutaneous burns have been known to develop secondary to cardioversion. The authors describe a novel case of the subsequent local progression of a previously sustained superficial flame burn to full-thickness burn injury after cardioversion.

Intracranial injury has been reported secondary to not only blunt and penetrating trauma but also thermal and high-voltage electrical injury. Reconstruction can be challenging, especially in the face of necrosis of large areas of the cranium. The authors present a novel case of fourth-degree thermal burn to the head caused by a rotating tire. Initial wound debridement exposed dura, prompting a dural patch and Integra® for temporary coverage. Definitive coverage was accomplished with a latissimus dorsi free flap. The injury was complicated by associated neurologic defects and seizure activity. However, management was effective, and at 1 year, the patient is alive and well.

The purpose of this study was to form a standard electrical trauma model in rat, to investigate the pathological changes in vessels, and to determine the best day for performing microsurgery. In the preliminary study, 20 rats were divided into five groups. One was control, and the rats in the other four groups were exposed to 240 V electrical potential for 5, 10, 15, and 20 seconds, respectively. Femoral vessels from each group were biopsied for electron and light microscopy. In the study group, 36 rats were subjected to 240 V electrical trauma for 18 seconds. The rats in the study group were divided into three groups. On days 3, 7, and 21, the femoral artery of nine rats in each group were cut and anastomosed. The anastomoses were followed for thrombus formation. Visible, respectively increasing necroses were seen in all animals in the second, third, and fourth preliminary study groups. Light and electron microscopy revealed degeneration of vessel walls and loss of endothelium. Second and third microsurgery study groups had statistically significantly more thrombus. Although after electrical trauma major vessels seem normal, they have pathological changes, and microsurgery success rates are decreased shortly after electrical trauma.

Electrical burns of the mouth are the most common electrical injury in children and can have serious, long-term functional and aesthetic consequences. Presented is a review of the pathogenesis of the associated injury and sequelae, as well as a case report. In the presented case, a multidisciplinary approach was used with input from pediatric dentistry, plastic/burn surgery, and oral and maxillofacial surgery. This collaborative effort and a novel microstomia prevention device produced a superior functional and aesthetic result. Without the aid of a microstomia device, the resultant contracture and associated functional deficits are difficult to release and reconstruct. Thus, proper timing and sequencing of treatment is critical.

By using the National Burn Repository, the authors sought to identify markers for injury severity and deep venous thrombosis (DVT) risk after electrical injury. They identified adult patients in the National Burn Repository who were admitted with an electrical injury between 1995 and 2007 (n = 1469). Patients who died within 24 hours or were admitted for less than 1 day and hospitals reporting no complications were excluded. Independent variables included TBSA burned, duration of intensive care unit stay and hospital admission, duration of mechanical ventilation, the number of operative procedures, amputation, and early fasciotomy. Early fasciotomy was defined as fasciotomy performed on a patient's first trip to the operating room and was used as a proxy for severity of electrical injury. DVT and death were the dependent variables. Among electrically injured patients, 10.4% had early fasciotomy. Patients who had early fasciotomy had significantly prolonged intensive care unit stays (10.3 vs 4.8 days, P < .001), hospital days (36.7 vs 17.1 days, P < .001), amputations (49.0 vs 4.6%, P < .001), and a number of operative codes (17.6 vs 5.4, P < .001). DVT incidence was 0.9%. Electrically injured patients who had early fasciotomy were significantly more likely to have a DVT when compared with patients who did not have early fasciotomy (7.55 vs 0.95%, P = .002). Early fasciotomy after electrical injury is a marker for increased injury severity. Among patients who underwent early fasciotomy after electrical injury, 7.5% develop DVT, and 49% require amputation during their initial hospitalization.

High-voltage electrical burns of the upper extremity are often limb threatening. Typically, emergency fasciotomies are followed by serial debridements until only viable tissue remains. After debridement, flap coverage is required to preserve viable but exposed tendons, nerves, vessels, bones, and joints and to salvage these seriously injured upper extremities. Flap options are generally limited to large pedicle flaps or free tissue transfer. Despite the array of flaps available, surgical options become limited when upper extremity injuries are extensive or the initial flap fails. The most commonly used pedicle flap, the groin flap, may not provide adequate soft tissue coverage in these cases. In addition, free tissue transfer can be difficult due, in part, to the uncertainty in determining the complete zone of injury and whether the flap recipient vessels are suitable for the transfer.An ideal flap for coverage would be relatively thin and pliable; have a constant, reliable pedicle; and be large enough to cover wounds of significant size. Few surgeons have experience with the pedicled tensor fascia lata (TFL) flap for upper extremity coverage. The authors demonstrate its use in the salvage of extensive upper extremity injuries on three limbs in two patients. We believe that this flap offers a distinct advantage compared with the groin flap when pedicled flap coverage of the upper extremity is required. PATIENT 1: A 23-year-old man sustained severe electrical burns to his right upper extremity. After serial debridements, a pedicled TFL myocutaneous flap was used to provide soft tissue coverage of this extensive injury. The flap was delayed at 2 weeks and inset at 3 weeks. There was complete survival of the flap, leading to salvage of the extremity. PATIENT 2: A 27-year-old man sustained bilateral upper extremity electrical burns. Initial free tissue transfers to both arms were unsuccessful. The patient subsequently underwent simultaneous bilateral pedicled TFL myocutaneous flaps. Both flaps were delayed at 2 weeks and divided at 3 weeks. There was complete flap survival bilaterally, leading to salvage of both upper extremities.Limb salvage in severe upper extremity electrical injuries is difficult even in the best circumstances. Dependable flap coverage is mandatory to prevent infection and avoid the need for early or late amputation. The pedicled TFL flap in our series of patients has served to be a dependable flap in these severe upper extremity injuries and should be added to the surgical armamentarium of those caring for these difficult surgical problems.

Rehabilitation of speech and swallowing postburns reconstructive surgery has not been previously described in detail in the literature. Severe facial burn injury requiring subsequent reconstructive surgery may result in complications including circumoral contracture and aesthetic and functional irregularities. These complications may manifest as facial and labial sensation deficits, poor oral access for intubation and oral/dental hygiene, and inadequate oral competence causing chronic drooling and poor articulation. This report describes the physical rehabilitation of a patient with full-thickness burns to the nose, lips, mouth, and chin following electrical burn injury. The severity of injury sustained placed the patient at high risk for microstomia, dysphagia, and speech disorder. A multidisciplinary team approach was used to coordinate the planning of reconstructive procedures, facilitate patient recovery, and optimize functional and aesthetic outcomes. Speech pathology intervention aimed to 1) facilitate safe transition from nonoral to oral intake, 2) improve articulation and speech intelligibility, and 3) minimize oral contracture development. At 6 months postinjury, the patient can safely tolerate a soft diet, demonstrate speech clarity at preinjury level, and has recovered functional oral range of movement. Rehabilitation of speech and swallowing is an essential factor to consider when planning postburn reconstructive procedures.

The aim of this study was to provide an increased level of evidence on surgical management of high-tension electrical injuries compared with thermal burns using a case-controlled study design. Sixty-eight patients (64 males, 4 females, aged 33.7 +/- 13 years) with high-tension electrical burns were matched for age, gender, and burnt extent with a cohort of patients sustaining thermal burns. Data were analyzed for cause of accident (occupational vs nonoccupational), concomitant injuries, extent of burn and burn depth, surgical management, complications, and hospital stay. High-tension electrical burn patients required an average of 5.2 +/- 4 operations (range, 1-23 operations) compared with 3.3 +/- 1.9 (range, 1-10 operations) after thermal burns (P = .0019). Amputation rates (19.7% vs 1.5%), escharotomy/fasciotomy rates (47% vs 21%), and total hospitalization days (44 d vs 32 d) were significantly higher in high-tension electrical injuries (P < .05). Creatinine kinase levels were significantly elevated during the first 2 days in patients with subsequent amputations. Free flap failure was observed during the first 4 weeks after the trauma, whereas no flap failure occurred at later stages. Local, pedicled, and distant flaps were used in 15% of the patients. The mortality in both groups was 13.2% vs 11%, respectively (nonsignificant). High-voltage electrical injury remains a complex surgical challenge. When performing free flap coverage, caution must be taken for a vulnerable phase lasting up to 4 weeks after the trauma. This phase is likely the result of a progressive intima lesion, potentially hazardous to microvascular reconstruction. The use of pedicle flaps may resemble an alternative to free flaps during this period.

The hands and forearms are frequent sites of burn injury, and due to the high concentration of superficial tendons, bones, and joints, flaps are frequently needed to cover defects in these areas. We present a patient who suffered remote electrical injury to the right forearm which later developed into an open wound with exposed tendon. Successful coverage of this defect was accomplished with an islanded fasciocutaneous flap based on perforating arterial branches of the radial artery, which was harvested from an area of burn injury. Surgical treatment of hand and forearm wounds with axial pedicled flaps from areas of burn injury have been reported, but to our knowledge no reports describe the use of perforator flaps.

Trauma patients with high-energy injuries often present with severe tissue damage that extends beyond the immediate zone of injury and require recruitment of vascularized and massive tissues. The objective of this study was to evaluate the utility of the island myocutaneous flap for the reconstruction of the electrical burn injuries on the cervical region. We conducted a retrospective chart review on all trauma patients treated by the Department of Plastic Surgery at Changhai Hospital, Second Military Medical University who required a large amount of vascularized tissue for the reconstruction of the electrical burn injuries on the cervical region from July 1994 to June 2006. Of them, 23 patients underwent reconstruction of severe traumatic deformities and disfunction on the cervical region with 23 island myocutaneous flaps from adjacent regions. Of the 23 patients, 17 were male and 6 were female, with an average age of 38 years. Conservative surgery method for debriding necrotic tissues and three different types of island myocutaneous flaps, including pectoralis major island myocutaneous flap, latissimus dorsi island myocutaneous flap and trapezius island myocutaneous flap were used. The defect area ranged from 6 cm x 4 cm to 20 cm x 15 cm. The sizes of the dissected myocutaneous flap ranged from 8 cm x 6 cm to 35 cm x 15 cm. All the 23 cases acquired complete recovery. The secondary defect of donor areas had primary closure after being directly sutured or covered with skin grafts. Island myocutaneous flaps have distinctive advantages in treatment of electrical burn injuries on cervical region and it can obtain satisfactory functional and cosmetic outcomes.

The 42 patients admitted to our Burn Center from January 1, 1994 to December 31, 2005, with electrical and fire burn injuries caused by electricity-conducting graphite-carbon fishing rods touching overhead high voltage electrical lines were epidemiologically studied retrospectively. All patients were men, with a mean age of 40.33 years. The majority of patients (59.5%) were burned with less than 10%, mostly deep burns. The hand was the predominant electricity "entry" point and foot was the most frequent "exit" point. Admissions increased from 5 in 6 years, 1994 to 2000, to 15 in 3 years, 2000 through 2002, to 22 cases in 3 years, 2003 through 2005. Spring and fall, and months May and October were times of highest incidence. The treatment was complex, difficult, long, and costly. Thirty-eight patients (90.4%) required operations, including early excision and graft (34 patients), and amputation (14 patients). Two patients had an inhalation injury that necessitated a tracheostomy and four victims had additional skin and soft-tissue injury. Thirty-two patients had a record of unconsciousness immediately after the electrical injury and atrial premature beats were a frequently found arrhythmia. A significant (P <.01) increase in serum creatine kinase MB fraction was found in 11 patients. The mean time in hospital of the survivors was 28.97 days. Acute renal failure was the commonest complication and one patient died of sepsis with giving a mortality rate of 2.4%. Caution and preventive measures are warranted while fishing near electrical wires, and improvements in electrical burn treatment are needed.

We sought to show how severe soft-tissue injuries of the proximal index finger caused by fourth-degree electrical burns to the hand may be surgically reconstructed. Soft-tissue coverage was provided with a reverse second dorsal metacarpal artery flap in two patients. Both digits were successfully salvaged by use of this reconstructive method. Both donor sites were closed primarily and healed without difficulty. The reverse second dorsal metacarpal artery flap provides well-vascularized tissue without excess bulk and allows near-normal hand function.