Industrial high-voltage electrical burn of the skull,a preventable injury

Deep burns of the scalp and skull are often caused by high-voltage electrical injuries. Patients with such injuries should be referred to regional burn centers that are prepared to excise necrotic burn tissue and cover the devitalized bone with a well-vascularized flap. Strategies for prevention of these electrical burns are discussed.     

Application of split-thickness dermal grafts in deep partial- and full-thickness burns: a new source of auto-skin grafting

Early tangential excision of nonviable burn tissue, followed by immediate skin grafting with autograft or allograft, has resulted in the improvement of burn patient survival. The aim of this study was to add split-thickness dermal grafts (STDGs) as a new source of auto-skin grafting tool to our reconstructive armamentarium in deep partial- and full-thickness burns and soft tissue defects. The authors successfully applied STDGs along with split-thickness skin grafts as a new source of auto-skin grafting in 11 deep partial- and full-thickness burns over a period of 1 year without any significant donor site morbidity. Dermal graft take was complete in all but one patient. There was no donor site healing problem, and donor site epithelization was completed generally 1 week later than split-thickness skin graft by semi-open technique. Autologous split-thickness skin grafting still remains the standard therapy for burn wound closure but may be in limited availability in severe burns. The authors conclude that STDGs may be a new source of auto-skin grafting tool in extensive deep partial- and full-thickness burns.     

腕部电烧伤创面修复的临床分析

目的腕部电烧伤创面修复的最佳皮瓣选择。方法将1994—2008年间应用皮瓣修复腕部电烧伤创面64例72个肢体分成两个组进行比较分析,一组为腹部带蒂皮瓣修复,另一组为局部轴型皮瓣及游离皮瓣修复。结果两组患者在伤情严重性、年龄和手术时间等方面均基本相同,但两组患者创面愈合率及深部重要组织保存,以及严重并发症发生有很大差异（P〈0．01）。结论用局部轴型皮瓣和游离皮瓣修复腕部电烧伤较用腹部带蒂皮瓣修复有明显优越性。     

Early upper-extremity prosthetic fit in patients with burns

Patients with upper-extremity amputations necessitated by burn injury have frequently faced delays in prosthetic fit. At the Regional Medical Center, Memphis, Tennessee, seven patients required amputations because of burns. These injuries were electrical in four cases, thermal and crush in one case, thermal in one case, and steam and crush in one case. Five patients had below-elbow amputations, one had a bilateral below-elbow amputation, and one had a bilateral above-elbow amputation. All patients were fitted with prostheses within 30 days of the last definitive surgery on the amputated extremity. All patients continued to wear a prosthesis and no patient exhibited skin breakdown. Patients returned to independence with self care within 2 weeks and to preamputation activities within an average of 2.5 months.     

前锯肌肌筋膜瓣移植修复足背大面积软组织缺损的临床效果

目的总结前锯肌肌筋膜瓣移植修复足背大面积软组织缺损的临床应用效果。 方法选择2015年1月至2019年1月，甘肃省兰州市兰州手足外科医院手外科应用前锯肌肌筋膜瓣移植修复足背大面积软组织缺损患者16例，其中，男11例，女5例；年龄24~50岁，平均（36.6±5.3）岁；软组织缺损范围为13 cm×8 cm~9 cm×6 cm。肌筋膜瓣切取连带肩胛下与旋肩胛血管，血管蒂近端呈“T”形，与受区胫前动脉两断端行端端吻合，肌筋膜瓣上用中厚网状游离植皮覆盖，供区创面直接缝合。 结果术后肌筋膜瓣全部成活，随访1.2~4.5年，平均（3.4±?2.3）年，受区和供区外形较好，优9例，良6例，可1例，优良率为93.75%，取得了较满意的效果。 结论前锯肌肌筋膜瓣移植手术操作安全、可靠，适于修复足背大面积软组织缺损，降低了对受区主要血管的损伤。     

A long-term study and correlation of lymphocyte and neutrophil function in the patient with burns

Twenty-five patients were studied to determine the effects of thermal injury on neutrophil bactericidal function and superoxide release and on lymphocyte proliferation. Neutrophils in patients with burns had depressed killing of Staphylococcus aureus for more than 150 days after burn injury, but killing of Escherichia coli returned to normal. FMLP-stimulated superoxide release by neutrophils in patients with burns was depressed for over 100 days after burn injury, whereas superoxide release by neutrophils in patients with burns stimulated with serum-opsonized zymosan was depressed for 42 days after burn injury. In patients with burns lymphocyte proliferation, with phytohemagglutinin as a mitogen, was suppressed for up to 85 days after injury, then returned to normal. The mixed lymphocyte response was suppressed up to 170 days after injury.     

应用不同部位游离穿支皮瓣修复小腿远端足踝部软组织缺损

目的探讨游离股前#l,f14、胸背动脉、腹壁下动脉穿支皮瓣修复小腿远端足踝部软组织缺损的手术技术及效果。方法对19例小腿远端足踝部皮肤软组织缺损患者进行修复,皮肤缺损面积（6emx9cm）～（11．6em~22．3em）。其中股前外侧穿支皮瓣12例、胸背动脉穿支皮瓣4例、腹壁下动脉穿支皮瓣3例。结果术后19例皮瓣全部成活。术后随访3—18个月,平均8．2个月,皮瓣颜色质地好,外形满意,两点辨别觉为9—21mm。结论游离股前外侧、胸背动脉、腹壁下动脉穿支皮瓣修复小腿远端足踝部软组织缺损临床效果满意。     

Salvage of ear cartilage in patients with acute full-thickness burns

Three cases in which the temporoparietal fascial flap was used to salvage denuded ear cartilage during the acute period after burn injury are reported. Patients' burns ranged from 30% to 75% total body surface area. The full-thickness burn was acutely excised, exposing the auricular cartilage. The temporoparietal facial flap was elevated and wrapped around the cartilage. The flap was then covered with a split-thickness skin graft. All flaps and skin grafts survived. Additional reconstructive procedures have been performed on two of the patients and are planned for the third.     

含真皮下血管网薄皮瓣在手部软组织缺损中的应用

目的总结含真皮下血管网薄皮瓣修复手部软组织缺损的临床治疗经验。方法 1992年6月~2010年3月期间,应用含真皮下血管网薄皮瓣修复手部软组织缺损27例。术后随访时间为3个月~3年。结果 27个皮瓣全部成活,皮瓣外形较好,术后3~6个月有触觉及痛温觉。患者手部功能恢复满意。手部外形接近正常,未见肌腱粘连及关节僵硬发生。结论真皮下血管网薄皮瓣修复手部软组织缺损效果好。     

股前外侧游离穿支皮瓣修复足踝部软组织缺损的临床观察

目的探讨股前外侧游离穿支皮瓣修复足踝部皮肤软组织缺损的疗效。方法选择收治的足踝部皮肤软组织缺损行股前外侧游离穿支皮瓣修复治疗的患者28例的资料为观察组,选择同期足踝部皮肤软组织缺损行传统交腿带蒂皮瓣治疗的患者23例为对照组,观察两组皮瓣存活情况、血运恢复及感觉恢复情况,并进行组间比较。结果观察组住院时间和治疗费用均少于对照组,皮瓣存活率、移植皮肤两点别觉均优于对照组,组间差异有统计学意义(P<0.05)。观察组患者皮瓣血运及外形良好,患者满意度高于对照组。结论股前外侧穿支皮瓣游离移植修复足踝部皮肤缺损,存活率高,可减少二次手术,并发症少,值得临床应用。     

Changes in the tissue and plasma superoxide dismutase (SOD) levels in a burned rat model

To examine whether thermal injury alters the superoxide dismutase (SOD) concentrations in various types of tissue or plasma, we studied the plasma and tissue Mn- and Cu/Zn-SOD levels in a rodent burn model. The animals were resuscitated with saline (50 mg/kg, i.p.) immediately following thermal injury and thereafter were sacrificed at either 6 or 24 hours post-burn. The Mn- and Cu/Zn-SOD levels were measured using an enzyme-linked immunosorbent assay (ELISA). The plasma Mn- and Cu/Zn-SOD concentrations significantly increased 6 hours after the injury and positively correlated with the burn size. The kidney Mn-SOD concentrations were significantly higher 24 hours after the injury in the animals with 30% burns than in those with either sham or 50% burn injuries. The lung Cu/Zn-SOD concentrations were also significantly higher 6 hours after the injury in animals with 30% burns than in the other two types above. These findings suggest that the changes in the SOD concentrations after burn injury vary according to the type of SOD and also the type of tissue. As a result, the SOD concentrations may play some role in the early response to thermal trauma.     

指背筋膜皮瓣修复手指皮肤软组织缺损

目的报道应用指背筋膜皮瓣修复手指皮肤软组织缺损的临床效果。方法应用指背筋膜皮瓣修复手指皮肤软组织缺损46例,并对皮瓣术后的外观、两点辨别觉及功能满意度进行随访调查。结果42例皮瓣成活无感染坏死,4例皮辩周围出现瘀紫水泡,适当将蒂部缝线拆除后恢复。随访3-18个月,皮辩的外观、两点辨别觉、功能满意度均良好。结论指背筋膜皮瓣具有操作简单、安全可靠、皮辫成活率高和外形、功能较满意等优点,不仅适合于手指普通的软组织缺损而且适合于需要重建良好感觉的指端及指腹缺损。     

Noncontact laser Doppler imaging in burn depth analysis of the extremities

The purpose of this study was to determine the accuracy and practical utility of a noncontact laser Doppler imager (PIM-II, Lisca Development AB, Link?ping, Sweden) in the estimation of burn depth in the upper and lower extremities. At 48 hours after burn injury, we performed scans of 35 burns in 22 patients and obtained histological samples for burn determination with hematoxylin and eosin and vimentin immunohistochemical staining. Additionally, sequential scans and tissue specimens were obtained on 10 burns at 24, 48, and 72 hours. A statistically significant inverse relationship was noted between burn depth and the laser Doppler perfusion index. Laser Doppler perfusion index values greater than 1.3 predicted a superficial dermal burn with 95% sensitivity and 94% specificity. Superficial dermal burns exhibited increased perfusion in the early burn period. Wounds showed a progressive decline in perfusion and a progressive increase in the depth of injury during a 72-hour period. This study demonstrates the advantage and accuracy of using a noncontact laser Doppler to differentiate deep dermal from superficial partial thickness burns in the extremities.     

股前外侧皮瓣带血管化的阔筋膜在跟腱及软组织缺损中的应用

目的探讨股前外侧皮瓣带血管化的阔筋膜修复跟腱及软组织缺损的临床效果。 方法自2012年10月至2014年12月,采用股前外侧皮瓣带血管化的阔筋膜治疗跟腱及软组织缺损11例。皮肤缺损4 cm×6 cm~9 cm×13 cm,跟腱损伤部分缺损或全部缺损,病例的缺损长度2~5 cm。根据创面大小及跟腱损伤或缺损的程度,切取相应大小的股前外侧皮瓣及阔筋膜,设计跟腱缺损区处于穿支血管蒂部,修复跟腱缺损。患足跖屈位术后石膏固定6周。供区行中厚皮片移植修复。 结果11例皮瓣全部成活。2例皮瓣边缘少许坏死,部分指肪液化,换药后愈合。部分植皮的供区植皮完全成活。随访6~12个月,跟腱张力恢复,踝部跖屈背伸功能正常。 结论股前外侧皮瓣带血管化的阔筋膜修复跟腱及软组织缺损效果良好。     

Forked finger fillet flap for segmental extensor tendon coverage of an adjacent digit.

Finger fillet flaps have been used to treat a variety of complex hand deformities providing stable soft tissue coverage and preventing pathologic contractures. Fillet flaps have not been reported in the coverage of segmental extensor tendon deficit in an adjacent digit. A 20-year-old man involved in a motor vehicle crash sustaining a 30% total body surface area burn, primarily to left arm and bilateral lower extremities. In particular, his left index finger extensor mechanism was disrupted with exposure of the proximal interphalangeal (PIP) joint. In addition, the middle finger had a segmental exposure of the extensor tendon. The nonfunctional index finger was sacrificed to provide coverage, via a forked fillet finger flap, of the exposed extensor tendon at the PIP and metacarpophalangeal (MCP) joints. Total active motion of left fingers at 12 months consisted of the third digit 0 to 86 degrees at the MCP joint, 0 to 88 degrees at the PIP joint and 0 to 33 degrees at the distal interphalangeal joint. Gross grip strength improved to 26 lb at 1 year follow-up. Adequate soft tissue coverage of extensor tendons can be challenging in the traumatic hand. With this novel approach of a forked finger fillet flap we were able to provide adequate soft tissue coverage of exposed tendons and joints improving the patient's strength and active range of motion especially in the middle finger. Prevention of postburn boutonnière deformity was an additional benefit.     

Electrical burns in Chinese fishermen using graphite rods under high-voltage cables.

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.     

Comparing a Single Institution's Experience With Electrical Injuries to the Data Recorded in the National Burn Repository

Electrical injuries usually represent a small proportion of a burn center's admissions. Although burn size may be small, internal tissue damage is sometimes extensive. This study reviews a single institution's experience with electrical injuries and compares it to the multi-institutional data of the National Burn Repository (NBR). The 2009 NBR and the records of a large urban burn center (single institution) were queried for adult electrical injuries over an 8-year period. Data examined included demographics, %TBSA burn, length of stay (LOS), injury circumstance, and disposition. Multiple linear regression models were created to determine factors related to LOS. One hundred ninety-one single-institution patients and 2837 multi-institution patients met the criteria. Both cohorts were mostly white males approximately 30 years of age and injuries where often work-related. Single-institution patients had a mean injury size of 4% TBSA, while multi-institution patients had 7%. The most common exposure source was domestic wiring for single-institution patients and electrical power plants/lines for multi-institution patients. Single-institution data showed that females had a shorter LOS than males (P < .0001). Single-institution data showed that independent risk factors for an increased LOS were infection, amputation, fasciotomy, and being Hispanic. Independent risk factors for multi-institution patients were being Hispanic and large %TBSA burn. There was no difference in mortality, gender, age, LOS, or intensive care unit LOS between the cohorts. In this analysis, there was no statistical difference between outcomes in the single- or multi-institutional groups. However, injuries reported in the NBR were slightly larger. In both cohorts, an increase in LOS was associated with %TBSA, as expected. Interestingly, Hispanic ethnicity correlated with an increased LOS. Future work will be aimed at understanding this correlation to determine whether it is specific to electrical injury or burns in general.     

STUDIES ON THE PATHOGENESIS OF STAPHYLOCOCCAL INFECTION : III. THE EFFECT OF TISSUE NECROSIS AND ANTITOXIC IMMUNITY

Necrosis of rabbit skin produced by thermal injury was found to result in a striking increase in local infectivity of staphylococci that were coagulase-positive and hemolytic, but no local increase in the infectivity of non-pathogenic staphylococci. Infection produced in necrotic burns extended beyond the area of burn and was characterized by hemorrhage, edema, and necrosis of contiguous normal skin. Such infections, however, never resulted in bacteriemia or metastatic abscesses, and there was no effect of the necrotic burn upon the infectivity of staphylococci injected into normal skin of the burned animal. Recovery of rabbits from severe burn infections was associated with the development of high titers of serum antibody to the alpha hemolysin or dermonecrotoxin of the staphylococcus. Thirty to 100 days after the initial burn infection, it was found that rabbits could no longer be infected in a necrotic burn, although infection induced in normal skin of these resistant animals was no different from that in normal rabbits. Immunity to infection by pathogenic staphylococci in necrotic burns could be induced by vaccination with potent alpha hemolysin toxoid, and this immunity was passively transferable with rabbit antiserum. No strain specificity was detected for this immunity in that immunization with toxoid prepared from bacteriophage type 52/42B/80/81 staphylococci protected animals against infection in a necrotic burn by other typable and non-typable staphylococci. Histopathological study of infected necrotic burns in normal rabbits showed extensive necrosis, hemorrhage, edema, and many masses of bacteria but leucocytic infiltration was observed only at the margin of the infection. In contrast, the infected necrotic burns in animals immunized with alpha hemolysin toxoid showed few bacteria and marked leucocytic infiltration throughout the burn. These experiments have, therefore, demonstrated a significant immunity to infection by pathogenic staphylococci in necrotic tissue but not in normal skin, associated with serum antibody to the alpha hemolysin or dermonecrotoxin of the bacteria. The implications of these findings are discussed.     

改良腰动脉筋膜皮瓣修复腰骶尾部软组织深度缺损

目的探讨应用改良腰动脉筋膜皮瓣修复腰骶尾部软组织深度缺损的手术方法及临床效果。方法 2006年2月至2010年6月收治16例腰骶尾部软组织深度缺损患者,缺损范围8.0cm×7.0cm～21.0cm×19.0cm。经创面处理后,行全麻或硬膜外麻醉,根据缺损部位及大小,设计以改良的对侧腰动脉后穿支为血管蒂的轴型筋膜皮瓣进行转移修复手术。术后3～5d拔除负压引流,10d间断拆线,12d全部拆除缝线。结果 16例皮瓣全部成活,其中2例创缘延迟愈合。术后随访1～4年,局部外形和功能恢复满意。结论改良的腰动脉筋膜皮瓣切取面积大,血供可靠,手术操作简单,容易掌握,用于修复腰骶尾部软组织深度缺损是一种较好的方法。