burns 33 (2007) 653665

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Electrical burn injuries

Some unusual clinical situations and management
Sreevalli Dega, S.G. Gnaneswar, P. Rambhupal Rao, Parvati Ramani, D. Mohan Krishna *
Plastic Surgery, Gandhi Medical College and Hospital, Hyderabad, AP, India

article info

abstract

Article history:

A retrospective and prospective management of 665 patients of electrical burn injuries out

Accepted 29 September 2006

of 10,000 burn cases admitted between 1996 and 2004 (9 years) was analyzed. The problems
encountered and their solutions are presented. One hundred and fifty-five (155) of them had

Keywords:
Electrical injury

their limbs amputated, i.e. (24%).

The pathophysiology of electrical injury is reviewed. Serial and multiple debridement of

Burn

wounds were performed, preserving the nerves, tendons, joints and bones even if denatured

Progressive necrosis

to preserve the continuity as these could regenerate partially if covered with vascularised

Vascular damage

skin.

Stable wound

Functional outcome of an electrical burn wound is inversely proportional to the time

Flaps

lapsed before start of reconstructive procedure/s. Infrastructural limitations like severe

Limb amputation

shortage of blood, and surgical materials due to a disparity between demand and supply
added to the poor general condition of the patient unfavorably delayed the start of
reconstruction and precipitated an unusual clinical situation. The aim of management
has been to obtain a healthy wound, which could support an inset of a skin edge. Under
these situations, a stable wound was obtained on the 12th day [average].
Split skin grafts and loco-regional flaps, using time-old principles of rotation, advancement, transposition served well in most of our cases. Through this paper, some unusual
wounds in unusual clinical situations, which were managed with various methods of
reconstruction, following the reconstructive ladder are presented.
# 2006 Published by Elsevier Ltd and ISBI.

1.

Introduction

Thermal injury due to electrical current is defined as tissue

injury by exposure to supraphysiological electrical currents.
Despite great advances in the treatment modalities of
electrical injuries in the last three decades, the magnitude
of the problem remains very high both for the victim and the
treating surgeon. Most of them succumb to it due to systemic
effect; many of those who survive, lose one or more limbs and
present with complicated defects involving different tissues at
different parts of the body. These wounds are often potentially
life threatening and some are functionally disabling.

The victims of electrical burns show certain specific features

with regard to therapy and the evolution of the pathology. The
very nature of electrical burns is its vascular damage leading to
progressive tissue necrosis, often seen in skin and muscles
[13,15]. This results in a gross limitation on manipulation of
local tissues for reconstruction. The optimal management of
these wounds therefore has evolved into a plan of primary
debridement, suitable decompression [10], an aggressive but
cautious revision debridement and early skin cover, often
composite, with an aim to preserve vital structures.
The problem of high risk wounds warranting priority in
providing an early and emergency cover compounded with

* Corresponding author at: 239, 4th Road, Mahendra Hill, East Marredpally, Secunderabad 500026, India. Tel.: +1 40 27730586.
E-mail address: gmcplasticsurgery@yahoo.com (D.M. Krishna).
0305-4179/$32.00 # 2006 Published by Elsevier Ltd and ISBI.
doi:10.1016/j.burns.2006.09.008

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burns 33 (2007) 653665

paucity and limitations of choice of procedures throw a great

challenge to the treating surgeon. Early debridement and
cover using a free flap is desirable [4,6,9], but not always
feasible. Local tissues transferred using time-old principles of
rotation, transposition, advancement, interpolation or axial
pattern served as a viable procedure for many of these cases of
severe electrical injuries.

2.

Materials and methods

Ten thousand consecutive burn patients were admitted in the

unit from 1996 to 2004 (9 years) out of which 665 patients
suffered electrical injuries, and formed the basis of this study.
A detailed performa is filled and documented from admission
to discharge. The protocol for treating these patients conformed to general principles of burns management. They are
Parklands formula for fluid replacement, forced fluids
administration to maintain a clear hourly urine output to
5075 ml/h, build up and maintenance of hemoglobin and
nutrition. Mannitol was occasionally used to force diuresis.
Sodabicarb was not used.
After the airway, breathing and circulation (ABC) of
treatment, the wound was cleaned with normal saline.
Suitable decompression was done to avoid compartment
syndrome. The wound was debrided, and gangrenous limbs
were amputated. Serial and multiple debridements of wounds
were performed but nerves, tendons, joints and bones even if
denatured were preserved as these could regenerate partially
if covered with vascularised skin. Muscles, both superficial
and deep were targeted and radical excision was carried out.
The wound was dressed with conventional dressing, or split
thickness skin graft or biological membrane. Blood transfusions
were given to maintain the hemoglobin. Once the wound was
stable without any progression of tissue necrosis, a definitive
cover with a skin graft or a flap was planned and performed.

3.

Relevant surgical pathology

Contact injury and flash burns [16,18]when electric current is

transmitted by means of a direct contact with a conducting
material like human skin or an arc reaches the surface, the
electrons begins to flow as ions in a solution. This electrolysis
is an exothermic reaction. It alters pH and oxygen level of
tissue fluids and releases toxins, which denature and destroy
the tissues.
Elecroporation is the rapid effect of current passing through
cell membrane. It denatures the cell membrane by affecting
the negatively charged proteins in the cell membrane and in
turn distorts the cell. This results in alteration of the
semipermeable quality of a cell membrane resulting in
haphazard flow of electrolytes. If the injury is not reversed
in time it leads to cell death. This, thus, differs from the
thermal injury.
Storage and dissipation of heat: electric current flows through
the path of least resistance. The flow, again, is direct or indirect.
Intact skin, fat, bone offer the maximum resistance. Therefore,
the resultant damage is greatest at the entry and exit points and
also in and around the bone as this is where muscles resides.

The muscles suffer maximum damage due to its proportionately higher volume. This also explains why tendons and
nerves at the wrist and ankle suffer more necrosis.
The damage done is three-dimensional and resulting
necrosis is progressive. Progressive necrosis is due to the
following factors [19].
(A) Heat generated at the time of passage of current. This heat
and the subsequent dissipation is the highest in and
around the bones and hence a progressive damaging
factor to the tissues.
(B) Edema within the tissues leading to compression and a
compartment syndrome.
(C) Denaturation and necrosis of the vessels and nerves due to
thermal and electrical damage. Intimal damage to the
vessels leads to occlusion and resultant vascular damage
to the tissues.
(D) Avascular necrosis of the smaller muscle bundles
Sandwich necrosis leading to death of muscle and
release of toxins, which in turn aggravates the damage of
uninjured tissues.
All these pathological factors lead to severe damage to the
soft tissues and bones, resulting in gangrene and amputation.
It also leads to progressive and continuing damage to normal
looking and relatively uninjured soft tissues.

4.

Results

Of the 10,000 burns admissions in 9 years, 665 cases of

electrical burns were present, constituting 6.5% (Table 1).
Five hundred and forty one of the 665 patients had hightension electrical current passing through the body with entry
and exit points. One hundred and twenty four patients
sustained flash or flame burns in addition to true electrical
burns. Of these 124, 26 suffered pure flame burns as a result of
electrical ignition (Table 1a).
Thirty-nine patients belonged to the pediatric age group,
between 1 and 15 years (Table 2). These were either domestic
accidents like accidental insertion of wet fingers into the open
sockets, or accidental contacts with high-tension wires often
during competitive kite flying. Six hundred and eleven (611)
patients were between 16 and 50 years, who were utility
workers in their active earning period. These were at the work
spots either due to contacts loose hanging and unprotected
wiring or with power line and industrial appliances transmit-

Table 1 Magnitude of the problem

Total burn
admissions

No. of electrical
burns

10,000

665 (785 wounds)

Percentage
6.65

Table 1a Type of current

True high voltage injury
Mixed-electrical and flame
Pure flame burns

541
98
26

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burns 33 (2007) 653665

Table 2 Distribution of age

Table 4 Region wise distribution

Age
115
39

1630
262

3140
266

4150
83

>51
5

ting high voltage energy. Ignoring the basic safety measures

prescribed for these contributed to the accidents in many
cases. Fifteen patients were above 50 years (Table 3).
Various parts of the body involved are shown in Table 4.
Multiple organ involvement throws a greater challenge to
reconstruction. More than one procedure has to be performed
in the same patients.
Amputation of one or more limbs occurred in 24% (155 out
of 655) (Table 5). One hundred and thirty-seven of these
presented with obvious gangrene resulting in amputations
[11]. The remaining 18 patients attempts to salvage failed and
we performed either amputation or revised the already
amputated stumps.
The time interval from the time of admission or injury to the
start of reconstructive procedures for a definitive skin cover
ranged from 5 to 25 days with a mean of 12 days (Table 6A).
Four thousand five hundred and four procedures were
performed in seven eighty-five wounds in six hundred sixtyfive patients (4504/785/665). Multiple procedures were done for
each patient and also each wound (Table 7).
Post operative or post trauma complications included
infection, progressive necroses of tissues, hemorrhage,
exposed blood vessels threatening a burst and complete
wound dehiscence. Neurological involvement with staggered
gait was a late complication. Others are poor functional
recovery of movement due to stiffness and partial or complete
loss of muscles and psychological, like depression. Cataracts
developed in one case.
Fifteen deaths are documented in the series. Twelve of
these were patients with flame burns of 50% and above. Of the
remaining three, two had hepatic failure and one had multi
organ system failure due to septicemia following multiple,
massive wounds. No case had a primary renal failure.
The following are some of the unusual cases with complex
and composite defects presented and treated in this series.

Scalp
Face
Chest
Abdomen
Lower limbs
Upper limbs
Hands and digits
Multiple parts
Amputations

Table 5 Procedures performed 4504

Debridement
Escharotomy
Split skin graft
Flaps
Amputation

2124
311
1200
714
155

and support. A separate exit point could not be found and the
resultant damage was compounded at the entry/exit point.
Reconstruction was done on the 11th day using a median fore
head flap for lining and scalping flap for the coverage. Hospital
stay was 30 days.

4.2.

Case 2 (Figs. 3 and 4)

Twenty-year-old female patient presented with high-tension

electrical injury with loss of half of face exposing right maxilla
and mandible and a partial loss of upper and lower lips. She
was lactating and hence we did not want to disturb her breast
for a DP flap. Secondly, conditions were conducive, like young
healthy patient, blood was available and so also infrastructure
for a microvascular transfer of tissue. Hence, a radial fore arm
free flap was used and vascular anastamosis done with the
facial vessels at the root of its origin from external carotid and
the external jugular vein. The hospital stay was 60 days.
An important point observed in this case was the superficial temporal vessels adjacent to the defect looked normal
with good pulsation but was not healthy for an anastamosis as
it resisted vascular dilation.

4.3.
4.1.

87
57
13
10
45
67
121
231
155

Case 3 (Figs. 5 and 6)

Case 1 (Figs. 1 and 2)

Thirty-year-old male patient presented with an electrical

injury of his nose involving full thickness loss of lining, cover

Eighteen-year-old female presented with partial loss of right

cheek, upper and lower lips. Reconstruction was delayed due
to non-availability of blood. A pectoralis major myocutaneous

Table 3 Age vs. etiology and type of current

015 years

1640 years

>40 years

Male

Female

Male

Female

Male

Female

Place of occurrence
Not work related
Work related

28
2

9
0

14
490

23
1

30
65

3
0

Type of current
High tension
Mixed
Flash or flame

20
6
4

7
1
1

427
64
13

2
20
2

85
7
3

0
0
3

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burns 33 (2007) 653665

Table 6A Time of presentation, start of definitive treatment, number of procedures and hospital stay
Hours after injury
06
624
15 days
>5 days

First aid,
casualty

Referral to plastic
surgery department

Start of definitive
treatment

No. of
procedures

563
90
2
10

478
195
2
10

211
442
2
10

1800
2660
8
36

Hospital stay
in days
58
62
49
53

Table 6B Analysis of treating methods

Part involved

Procedure
SSG

Scalp
Face
Chest
Abdomen
Lower limb
Upper limb
Hand
Multiple

Local flap

Distant flap

Free flap

91
59
9
3
51
2
24
126

0
0
0
1
2
66
98
258

0
1
0
0
4
0
0
0

20
57
74
246
170
159
319
156

flap was used for lining and delto pectoral flap for coverage.
Later a commissurotomy was performed to increase the oral
aperture. Hospital stay was 60 days. She developed cataract on
the affected site.

4.4.

Case 4 (Figs. 7 and 8)

A 10-year-old boy suffered a high voltage injury while flying a

kite, which resulted in a deep wound on the left thorax
exposing heart and the pericardium. A rectus abdomonis
muscle flap transpositioned into the defect and a skin graft to
cover the muscle. Patient was well after 3 years with stable

Table 6C Various flaps used

Loco-regional
Local transposition
Axial pattern
Forehead
Deltopectoral
PMMC
Lateral arm
Posterior interosseous

310

5
4
1
2
2

Muscle flaps with SSG

Gastrocnemius, RAM, LD
Fascialtemporal fascia

27
2

Perforator-based
Reverse sural
Bilateral sural

21
1

Distant
Abdominal
Groin
Cross leg
Cross finger
Free
Radial forearm
LD with SSG

242
180
1
3

1
4

Infection

Single

Multiple stages/
repeat surgery

2
0
1
2
35
7
19
359

31
8
12
9
5
4
17
0

72
149
1
1
37
63
104
413

Hospital
stay-days
25
19
39
43
57
25
35
72

wound and an accepted visible heart beat. The hospital stay

was 50 days.

4.5.

Case 5 (Figs. 9 and 10)

A similar case with exposed ribs, liver, pleura and diaphragm on

left side was treated with ipsilateral Latissimus Dorsi muscle
flap and skin graft on the 15th day. Hospital stay was 40 days.

4.6.

Case 6 (Figs. 1114)

Thirty-year-old male presented with abdominal wound at the

right iliac fossa with exposed intestines, which was covered
with a split skin graft. He had bilateral amputation of upper
limbs and hence shoulder muscles were spared for the use of
prosthesis. The wound healed but the bag of intestine covered
with skin graft herniated into the abdominal defect groin flap
was designed to cover the defect which was reinforced with a
Prolene mesh but suffered a partial flap necrosis. An omental
flap was tunneled beside the laparotomy wound into the
defect and this was covered with a skin graft. Hospital stay
was 90 days.

Table 7 Complications and sequle

Hemorrhage
Infection
Progressive necrosis
Cataract
Exposed vessels
Nerves
Tendons
Joints
Bones
Heart, lung, liver
Intestines
Wound dehiscence
Kinetic dysfunctions
Death

10
105
625
1
4
76
135
12
65
2
1
45
140
15

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burns 33 (2007) 653665

Fig. 1 Full thickness loss of nose-lining, support and

cover.

4.7.

Fig. 3 Hemi facial lossmandible maxilla and partial loss

of both lips and cheek.

Case 7 (Figs. 1517)

Thirty-year-old male, presented with an extensive and deep

circumferential wound at the groin exposing the femoral
vessels and the genitals a through debridement was done and
the wound was covered with a split thickness graft. The exit
wound at the foot was exposing the calcaneum and was
covered with a reverse sural flap. Hospital stay was 50 days.

4.8.

Case 8 (Fig. 18)

Twenty six-year-old male had exposed right subclavian

vessels on the 8th post injury day at the neck. This threatened

Fig. 4 Radial foream free flap.

a secondary hemorrhage which would have resulted in the

loss of surviving limb. The upper limb was already amputated.
This wound was covered with an ipsilateral LD flap, which was
tunneled through the axilla and brought to supraclavicular
area as an emergency procedure and thus the limb was saved.
Hospital stay was 30 days.

4.9.

Fig. 2 Median forehead flap-two stage.

Case 9 (Figs. 19 and 20)

Thirty-five-year-old male presented with the injury exposing

the neck of the humerus with loss of pectoralis tendon. Neo
insertion of pectoralis major was done; the sternal head of the

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burns 33 (2007) 653665

Fig. 5 Hemifacial loss.

Fig. 7 Chest wall loss with exposure of heart and ribs.

muscle was detached and rotated with the clavicular head as

the pivot point and inserted subperiosteally into the lateral lip
of the bicipetal groove. This neo-insertion retained partial
adduction at the shoulder. Hospital stay was 20 days.

4.10.

Case 10 (Figs. 2123)

Wounds on the scalp and nape of the neck were initially

covered with a SSG and later used a transposition bucket
handle type of flap from the remaining scalp. This patient
developed an ataxia with rigidity of limb muscles. Hospital
stay was 90 days.

Fig. 8 Rectus abdominis muscle with SSG.

4.11.

Case 11 (Figs. 24 and 25)

Fifty-year-old male had a localized full thickness burns

exposing the flexor tendons at the wrist and hypoesthesia
of digits. An island posterior interosseous flap was used to
cover this defect after 9 days. He recovered fully the sensations
after wound cover and stayed in the hospital for 16 days.

4.12.

Fig. 6 Lining with PMMC and cover with deltopectoral.

Case 12 (Figs. 26 and 27)

Exit wound on both legs Exposing Tibia, covered with bilateral

reverse sural flaps. Hospital stay 75 days.

burns 33 (2007) 653665

Fig. 9 Chest wall loss with exposed pleura, ribs, liver and
diaphragm.

5.

Discussion

5.1.

Magnitude of the problem in the given center

659

Fig. 11 Abdominal defect with exposed viscera. Loss of

both upper limbs.

Six hundred and sixty-five victims of electrical burns were

treated, which constituted 6.5% of burns admission in a plastic
surgical department treating burn injury in the general
hospital set up. World literature reports 3.56.5% of electrical
injury [20] (Table 1).

Fig. 12 Prolene mesh support and cover with groin flap.

5.2.
Etiology of domestic and pediatric burns differ from
the west (Tables 2 and 3)

Fig. 10 Latissimus Dorsi muscle with SSG.

The victims in this series ranged between 5 and 70 years.

Pediatric patients between 1 and 15 years constituted thirtynine (39). Five patients belonged to above 50 years. All these
were domestic incidents. The causes were inserting fingers in
the open sockets at home, accidental contact with hightension wires during kite flying, adjusting the TV antenna or
trying to dry clothes on these high-tension wires. Electrocution while walking on flooded roads during rains also
contributed to this havoc. Most of these are preventable with

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burns 33 (2007) 653665

Fig. 15 Circumferential defect of the groin, exposing

femoral artery, genitalia. Exit wound at the calcaneum.

Fig. 13 Marginal necrosis exposing the mesh, covered

with Omental flap and SSG.

a little care and concern by the parents on one hand and the
maintenance staff of our electricity department. In contrast, in
developed nations, children suffered electrical burns either
accidentally due to heating elements, and domestic appliances [20] like water heater, room heaters, etc. Child abuse is
often reported from the west while this was conspicuously
absent in this series. A high degree of protection and concern
by parents and paucity of electrical gadgets at most of the
houses could account for this low incidence of domestic
electrical burns.

Fig. 16 SSG.

5.3.
Industrial accidents and work related injuries
compromise on safety and prevention

Fig. 14 Final healed wound.

Six hundred and eleven (611) cases of these 665 (91%) belonged
to age group of 1650 in the prime phase of life. These occurred
either at the work spot or work related travels on roads as
mentioned in the forgoing paragraph. They accidentally come
into contact with loose hanging un-protective high-tension
wires. Time and again incidents occur in small productive
factories where these workers have to handle improperly
grounded electrical appliances. Many of these victims suffer
the injury as they evade safety measures prescribed by the
factory-act and this compromise on rules is a common
feature in our country. Negligence, no fear of punishment and
callous attitude on the part of the employers over the
employee could contribute to these ghastly injuries. Education

burns 33 (2007) 653665

Fig. 17 Reverse sural artery flap for the ankle wound.

661

Fig. 19 Exposed neck of the humerus with loss of

pectoralis major tendon insertion.

on safe handling of electrical machinery, stringent punishment on evasion of safety devices go a long way in preventing
some of these incidents. In all these, the victims were the wage
earners and we ended up with tremendous loss of man-hours
(Tables 1a3).

5.4.

Amputations

One hundred and twenty-five patients underwent a total of

155 amputations, 18 of them suffered multiple amputations of
more than one limbs (24%). This is low as compared with the
reported figures [8,20], which range from 32% to 51% (Table 5).

Fig. 20 Pectoralis major sternal head detached, pivoted

about the clavicular head-neo-insertion.

True high voltage electrical burn injuries resemble a

crush syndrome [1,3]. The damage to the tissues is threedimensional with the current producing extensive necrosis of
the tissues at different levels from skin to bone.

5.5.

Fig. 18 Subclavian artery exoposed in the single surviving

upper limb. LD transposition flap saved the limb.

Entry and exit points

The contact wounds are usually present at the entry and exit
points and the injury more severe at these two points. The
terminology of entry and exit point, however, is an archaic
term [1] for the simple reason that they are applicable to direct

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burns 33 (2007) 653665

Fig. 21 Scalp and nape of the neck with exposure of

cranial bone.

Fig. 23 Transposition using Bucket Handle principle.

current whereas in an alternate current the exit point becomes

the entry (re-entry) point also. The resultant damage is more
severe (case 1).

5.6.

Decompression, fasciotomy, escharotomy

The thoroughness of debridement to produce a viable tissue

bed is important; the crucial decision is the correct time of
intervention and the correct depth. Four thousand five
hundred and four procedures were performed on 785 wounds.
Multiple debridements were done on each wound, ranging
from 2 to 17, average (9) (Table 5). Early surgical decompression

Fig. 24 Exposed flexor tendons and PL with nerve at the

forearm.

and fasciotomy did not significantly influence limb losses in

our series. Favorable results with decompression are reported
in literature [2,3,10,23] in limb saving and restoring vascularity. The late arrival of our patients could be the reason for this.

5.7.

Fig. 22 SSG initially.

Ideal management versus optimal management

The defect versus cover is like matching the following

questionnaire; debridement and primary cover is desirable.
Radical early excision (25 days) and instituting a primary
cover with free flap has yielded good results and saved many

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burns 33 (2007) 653665

Fig. 26

Fig. 25 Posterior interosseous flap transposition.

limbs [4,6,24]. The site and extent of tissue necrosis can be

clearly identified by 99 T Cm-MDP bone scans [12].
The type of reconstruction for each injury depends on
various factors like risk of surgery, general condition of the
patient team-experience, infrastructural resources and limitations and above all patients preference and need [2,5,6,14].
Microvascular surgical facilities are available, but it drains the
hospital of its available limited resources in terms of staff
time, and theatre time in proportion to the huge volume of
patient load. Bone scans are useful adjuvant but not accessible
to our type of patients.

Fig. 27

Table 8 Overall view of the 12 cases

S.no.

Age/sex

Time interval (days)

Problem

30/m

11

27/f

3
4
5
6

18/f
10/m
35/m
35/m

19
6
15
12

Full thickness loss of the nose-cover,

lining and support
Hemi facial loss with exposed right maxilla,
mandible and partial loss of both lips
Loss of lower lips and cheek
Chest wall loss with ribs exposing heart
Exposed pleura, liver and diaphragm
Abdominal defect with exposed bowels.
Loss of both upper limbs

30/m

26/m

35/m

10

35/m

14

Scalp defect

11
12

50/m
26/m

9
15

Exposed FCR and PL at near the wrist

Exit wound on both legs Exposing Tibia

Injury at the groin, exposing femoral artery,

genitalia and calcaneum at the exit wound
Amputation of the left upper limb. Exposed
the right subclavian vessel at the
supraclavicular area
Exposed neck of humerus with loss of
pectoralis tendon attachment

Solutions
Median forehead flap for lining
and scalping flap for cover
Radial forearm free flap
Lining with PMMC and cover with DP
Rectus abdomonis muscle flap with SSG
Latissimus Dorsi muscle flap with SSG
Prolene mesh covered with groin flapmarginal necrosis of the flap with
omental flap with SSG
Simple SSG for the groin; Sural flap
for the calcaneum
Cover with LD

Pectoralis major sternal head

was detached, pivoted about the
clavicular headneo-insertion of DP
SSG followed by transposition
flap-bucket handle
Posterior interrosseous flap transpositions
Bilateral reverse sural flaps

664

burns 33 (2007) 653665

5.8.
Serial debridement12 days to obtain a viable and
stable wound
The degree of tissue damage is more extensive than that
perceived on initial examination due to the progressive and
continuing tissue necrosis. This results in a wound, which is
unable to accept a flap inset at the margins and inadequacy
of the cover designed primarily due to widening of the defect
due progressive tissue necrosis. The delayed flap cover is
fraught with the obvious danger of loss of vital tissues and
life and thus defeats the very purpose of wound cover.
Hence, a compromise was to be taken through multiple
serial debridement (Table 8). Twelve days (12) was found as a
viable alternative and gave good results, the wound edges
were stable and the flap could be inset without breakdown.
High complication rate is reported with electrical injury
including partial or complete flap failure [7,8]. This fact,
associated with the need to preserve the vital organs and
structures like vessels, bones, tendons and nerves justifies a
cautious reconstructive approach with serial examination
and debridement prior to a definitive surgery. The vascular
damage and resulting thrombotic phenomenon abates
during second week and tissues become healthy. This is
the time when tissues around the wound withstand
manipulation for a local, regional or axial flap. Constant
effort is being made to reduce this period to 57 days to be
comparable to internationally accepted time when we can
reduce the complications like infection. In selected cases,
microvascular transfer of flaps gave good results (five free
flaps).

5.9.

Clinical situation as the deciding factor

The ideal procedure differs from patient to patient and

wound to wound [3,6,9,14,17,20]. No two wounds are
identical. The choice of procedure therefore has to be
Tailor-made for the given situation (Table 5). The clinical
status of the patient at the time of presentation, number and
progress of the of wounds, age, occupation, availability of
blood and ability to allot staff time all contribute in varying
degree to the choice of procedure and precipitates an
unusual clinical situation, which is peculiar to a developing
country. This is the deciding factor for choosing a procedure
[8]. To site an example from our series, case 2 in which the
clinical situation favored a free flap cover, where as case 3
though similar in all respects, no blood was available and
patient refused to arrange for the same and hence a staged
procedure was undertaken without compromising functional
results.

5.10.
Loco-regional flapssimple solution to complex
problem
Loco-regional flaps have served extremely well in the
management of these severe, devastating electrical injuries.
The advent and versatile myocutaneous, fascicutaneous and
muscle flaps have significantly influenced the optimum
management of electrical burn wounds. Split skin graft, either
as an intermediate biological cover or as a definitive
procedure, plays a great role (Tables 6A6C).

5.11.

Complications (Table 7)

The complications in the present series included limb loss,

wound sepsis, neurological deficiencies and staggered gait
and, early development of cataract [22]. Fifteen patients died;
12 of them were those who sustained flame burns and of
severe nature with BSA more than 50%. Of the three, two had
hepatic failure and one had MOF [21]. Thus, the electrical burn
victims had good survival but very poor functional recovery.

6.

Conclusion

(1) Six hundred and sixty-five victims of electrical burns were

treated, which constituted 6.5% of burns admission World.
(2) Six hundred and thirty nine of them were high voltage
injuries.
(3) The relevant pathophysiology is recognized.
(4) Unusual clinical situation is defined and influenced the
performance.
(5) Serial debridements were undertaken before the wound
was free from progressive necrosis of tissues and flap inset
was safe. Such a wound was obtained in 12 days.
(6) Loco-regional flaps served well to cover these wounds.
(7) Limb loss was 24% and was lower than the reported figure.
(8) Twelve representative cases were presented.

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