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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 23  |  Issue : 1  |  Page : 84-87

Post electrical injury anterior chest wall defect reconstruction in an infant


Department of Burns, Plastic and Maxillofacial Surgery, Safdarjang Hospital and Vardhman Mahavir Medical College, New Delhi, India

Date of Web Publication11-Dec-2015

Correspondence Address:
Dr. Sanjay Kumar
Rameshwar Apartment, Flat 21, Near Bhootnath More, Kankarbagh, Patna, 800026, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-653X.171664

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  Abstract 

Electrical injuries cause devastating and major trauma at the site of contact as well as in other parts of the body. The contact over chest and abdomen invariably results in full thickness injury. Management of these full thickness defects is a great challenge for the burn surgeon. In this article we report the first case of full thickness chest wall defect following electrical injury in an infant following contact with household 230 volt current. A delayed primary reconstruction of the chest wall was carried out using pedicled latissmus dorsi myocutaneous flap.

Keywords: Chest wall reconstruction, electrical injury, electrical burn, infant, skin substitute


How to cite this article:
Agrawal K, Kumar S, Dhaka T, Sharma S. Post electrical injury anterior chest wall defect reconstruction in an infant. Indian J Burns 2015;23:84-7

How to cite this URL:
Agrawal K, Kumar S, Dhaka T, Sharma S. Post electrical injury anterior chest wall defect reconstruction in an infant. Indian J Burns [serial online] 2015 [cited 2019 Nov 20];23:84-7. Available from: http://www.ijburns.com/text.asp?2015/23/1/84/171664


  Introduction Top


Electric injury is infrequent worldwide but it is associated with high morbidity and mortality. [1],[2] Adults are at high risk to such type of injuries as compared to children. [2] It is extremely rare in infants. [3],[4] Children mostly sustain electric injuries while playing and adults at their work place [5]

There is not much of epidemiological data available on electric burn especially in pediatric age-group. In most studies and case reports, children less than 6 years [4] are more prone to oral contact injuries by biting, chewing or sucking electric cord and cable wires [6],[7],[8] , more so in males. [4]

Electricity has a devastating potential to cause full thickness defect at the site of contact requiring surgical debridement and cover. [1],[9],[10],[11],[12] Delay in surgical intervention increases the morbidity and mortality. Electric injuries to vital organs are a life threatening condition. [1],[5],[10],[11],[12]

Post electric chest wall defects are rare [1],[10] and present a great challenge. [11],[12] To the best of our knowledge this report presents the first report of an anterior chest wall burn in an infant, caused by domestic 230 volt current. We did not come across any report of such chest wall defect in an infant on PubMed and google search. A delayed primary reconstruction of the chest wall defect has been carried out using pedicled latissmus dorsi myocutaneous flap and split thickness skin graft. Furthermore, this article emphasises the need to aggressively treat the electrical burn injuries for favorable outcome.


  Case Report Top


A 10-month-old male child (weight 8.5 kg) was brought by his parent to our burn casualty with alleged history of electric injury. He sustained the injury at home while he was crawling on the floor; the baby came in contact with the base of a table-top fan kept on the ground which had current due to short circuit. The child had sustained burn over the chest and face. After primary treatment the child was referred to our casualty for management.

Patient reached our burn emergency services within 5 hours of injury. He was conscious and crying with vital parameters within normal limits. The child had 10% TBSA burn as assessed using Lund and Browder chart involving right anterior chest wall, right cheek involving oral cavity and right arm [Figure 1]. All the burn areas were deep with evidence of deep eschar. Right side chest wall wound was measuring 12 × 18 cm size, firmly fixed to underlying ribs. ECG and initial base line hemogram were essentially normal. The child was adequately resuscitated and preliminary dressing was done using 1% silver sulphadiazine cream. Systemic management included blood transfusions, parenteral antibiotics, analgesics and others according to requirement. Special emphasis was given to the nutrition and chest physiotherapy, though the physiotherapy was difficult as the child was too young.
Figure 1: Electric injury wounds over the chest of the infant. Second post burn day picture


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Considering the age of the patient, conservative debridement was performed on 5 th post burn day. 4 th , 5 th , and 6 th ribs and costochondral junctions were exposed. There were doubtful areas of necrosis between the ribs. Intercostal muscles were left for further observation. Since there was doubt about the completeness of the debridement and possibility of progressive necrosis due to electrical burns, primary reconstruction was deferred. The defect on the chest wall was covered with bilaminar biocollagen skin substitute Therafoam (M/s Regrow, Mumbai) [Figure 2]. The postoperative period was uneventful. The silicone layer came off spontaneously after 4 days. The collagen layer also came off on 7 th postoperative day. The ribs were exposed and the cartilages appeared to be partially devitalized. Definitive reconstruction was further deferred. Debridement of face burn was also performed in same sitting and covered with bilaminar biocollagen skin substitute Therafoam.
Figure 2: After first debridement and placement of bilaminar biocollagen sheet as skin substitute


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On 18 th post burn day the reconstruction of the chest wall was planned. Patient was hemodynamically stable, nutritional parameters were optimal and general condition was good to undergo definitive chest wall reconstruction. There was no paradoxical movement of chest wall. The plan was to provide a vascularized cover to the partially devitalized ribs and exposed pleura between ribs, with a latissimus dorsi myocutaneous (LDMC) flap, hoping that it would augment the vascularity of the ribs. After thorough debridement, the flap was raised with 15 × 8 cm muscle (larger) and 15 × 5 cm skin paddle (smaller) to cover the defect, so that donor site would be closed primarily [Figure 3]. Part of the muscle was split skin grafted. Remaining face burn raw area was skin grafted. Post op course was uneventful, and the wound healed in 3 week time.
Figure 3: Raising of the Latissimus dorsi Myocutaneous flap adjacent to the chest wall defect


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At 3 months follow-up, flap and graft were well settled. The child was thriving well with good lung expansion and chest wall stability. Since there was no discharge from the wound, and no other local/systemic evidence of infection, no bone scan was performed to assess the vascularity of the ribs [Figure 4].
Figure 4: Healed chest wall wound. No paradoximal movement and good aesthetic reconstruction of chest wall


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  Discussion Top


Indian household electrical circuit has a low tension current. This current causing full thickness chest wall defect is not very common. [4] This could be a professional hazard in adult males. [5] But it is extremely rare in pediatric population and more so in infants with age less than 1 year. [4],[6]

In India the electrical current is 220-230 Volts, 50 Hz alternating current. Because of relative higher voltage than many other countries, the risk of deeper injury is higher with Indian regular household current. Short circuit in appliances, bare live wiring, faulty electrical connections are quite common occurrence in developing countries like India. The electrical injury causing deep chest wall injury is of common occurrence in adults as they are likely to come in contact with high tension wires. However, these injuries are extremely rare in children.

The child presented was 10 months old with 8.5 kg weight and 8 g% hemoglobin. It was considered that there is a risk of inadequate eschar excision or there is a possibility of development of delayed necrosis of adjacent tissues, hence definitive reconstruction was delayed. The team chose the later considering the age, weight of the child and specially the type of injury. In electrical burns, more often than not reconstruction is always delayed because of the possibility of progressive necrosis.

Initially bilaminar biocollagen sheet (Therafoam) was used which stayed for 7 days on the wound. This came off spontaneously exposing the ribs and external pleura. However it took care of the critical initial postoperative period. The delayed primary definitive surgery using LDMC flap was simple and a routine procedure. The LD muscle and myocutaneous flaps are the workhorse of anterior chest wall reconstruction. [1],[9],[10] The differential dimension of muscle and skin paddle is an interesting concept and perfect for the child. The small skin paddle allowed primary closure of the donor area and large muscle segment permitted complete closure of the recipient chest wall defect.

Alternative muscle and myocutaneous flaps used for chest wall defects are extended reverse double turn over deltopectoral flap [11] , pedicle full thickness abdominal flap [12] and cervicohumeral flap. [13] Other available myocutaneous flaps for anterior chest wall defect are contralateral Pectoralis Major, Serratus anterior, External Oblique, Rectus Abdominis, Omental flaps, or free flap. Among them LDMC flap was most appropriate on risk benefit ratio, to use with little functional loss of climbing and swimming later on.

The ribs were exposed and the vascularity was doubtful as anticipated because of the direct contact with electrical appliance. However it was left under vascular LDMC flap expecting it to vascularize and survive. This prevented the risk of paradoxical movement of the chest wall and also avoided the need of skeletal reconstruction in this small baby.

Anterior chest wall defect reconstruction poses a great challenge for surgeons confronting them. [11],[12] Delay in surgical intervention can increase the morbidity associated with deep electrical injuries. [1],[2] In electrical injuries of the chest wall, early coverage is a matter of great concern specially in children, because of anticipated complications in view of exposed ribs and pleura. [14]

To conclude, full thickness electrical injury requires aggressive surgical management. However, in an infant with relatively low threshold of anesthetic risk, conservative approach with staged excision and reconstruction may be a way to manage. This may minimize the anesthetic risk and surgical trauma. When a delayed primary reconstruction of a critical defect is planned, use of skin substitute is of great help.

 
  References Top

1.
MacKinnon C, Klassen M, Widdowson P. Reconstruction of a severe chest and abdominal wall electrical burn injury in a pediatric patient. Plast Reconstr Surg 1999;103:1775-7.  Back to cited text no. 1
    
2.
Koumbourlis AC. Electrical injuries. Crit Care Med 2002;30:S424-30.  Back to cited text no. 2
    
3.
Burke JF, Quinby WC Jr, Bondoc C, McLaughlin E, Trelstad RL. Pattern of high tension electrical injuries in children and adolescent and their management. Am J Surg 1977;133:492-7.  Back to cited text no. 3
[PUBMED]    
4.
Baker MD, Chiaviello C. Household electrical injuries in children. Epidemiology and identification of avoidable hazards. Am J Dis Child 1989;143:59-62.  Back to cited text no. 4
    
5.
Yeroshalmi F, Sidoti EJ Jr, Adamo AK, Lieberman BL, Badner VM. Oral electrical burns in children-A model of multidisciplinary care. J Burn Care Res 2011;32:e25-30.  Back to cited text no. 5
    
6.
Valencia R, Garcia J, Espinosa R, Saadia M, Valencia E. 14 yr follow up for a severe electrical burn to mouth and lip: Case report. J Clin Pediatr Dent 2010;35:137-44.  Back to cited text no. 6
    
7.
Keskin M, Tosun Z, Duymaz A, Savaci N. Perioral electric burn in children: Case report. Ulus Trauma Acil Cerrahi Derg 2008;14:326-9.  Back to cited text no. 7
    
8.
Masanès MJ, Gourbière E, Prudent J, Lioret N, Febvre M, Prévot S, et al. A high voltage electric burn of lung parenchyma. Burns 2000;26:659-63.  Back to cited text no. 8
    
9.
Bostwick J 3 rd . Latissmus dorsi flap: Current applications. Ann Plast Surg 1982;9:377-80.  Back to cited text no. 9
    
10.
Kumar P, Varma R. Immediate reconstruction of chest and abdominal wall defect following high voltage electrical injury. Burns 1994;20:557-9.  Back to cited text no. 10
    
11.
Nnabuko RE, Anyanwu CH, Ezinwa CO, Isiguzo CM, Uduezue A. Reconstructive challenges in full thickness left anterior chest wall defect following electrical burn: A case report demonstrating the use of extended reverse double turnover deltopectoral flap. Burns 2011; 37:e37-40.  Back to cited text no. 11
    
12.
Zhao JC, Xian CJ, Yu JA, Shi K. Pedicled full thickness abdominal flap combined with skin grafting for the reconstruction of anterior chest wall defect following major electrical burn. Int Wound J 2013;12:59-62.  Back to cited text no. 12
    
13.
Capar M, Karataŝ O, Gözel B, Oztan Y. Anterior chest wall reconstruction with cervicohumeral flap. Ann Plast Surg 2000;44:114-5.  Back to cited text no. 13
    
14.
Alfie M, Benmeir P, Caspi R, Raveh T, Moor E, Weinberg A, et al. Costal osteomyelites due to electrical burn. Burns 1995;21:147-8.  Back to cited text no. 14
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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