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CASE REPORT
Year : 2022 | Volume
: 30
| Issue : 3 | Page : 79-81
A severe electrothermal ring burn case and a proposed treatment algorithm
Burak Ozkan, Abbas Albayati, Suleyman Savran, Cagri Ahmet Uysal
Department of Plastic Surgery, Baskent University Hospital and Faculty of Medicine, Ankara, Turkey
Correspondence Address:
Prof. Burak Ozkan
Department of Plastic Surgery, Baskent University Hospital and Faculty of Medicine, Ankara
Turkey
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/tjps.tjps_8_22
Ring-associated burns are infrequent comprising only a tiny fraction of burn consults. Due to the circular nature of rings, these burns are often circumferential, with an increased risk for compartment syndrome and neurovascular injury. The severity of ring burn is related to the type of material and electrical current. Low-voltage injuries are generally due to contact with batteries and household devices, while high-voltage electric injuries occur with occupation-related accidents or natural disasters. Low-voltage ring burn can be managed conservatively with close follow-up. However, high-voltage ring burn might have dramatic consequences such as finger amputation. To date, there have been few cases reported in the literature of a ring burn. Most cases were superficial burns and managed with secondary healing or skin grafting. However, the literature has not reported the management of a severe ring burn with deteriorated finger circulation. In this case report, we present a circumferential electrothermal ring burn case with resulted in total loss of a finger. Furthermore, we propose an algorithmic approach to ring burn injuries.
Keywords: Algorithm, electric, finger, ring
Overall electrical burn injuries to the fingers from alloy rings are infrequent.[1] The circular nature of rings causes circumferential burns, which might compromise the circulation of fingers.[2] Even though burn size is typically small, the digits may have an amputation. To date, finger loss due to an electrothermal ring burn has not been reported in the literature. We present a circumferential electrothermal ring burn case that resulted in the total loss of a finger. Also, we propose an algorithmic approach to ring burn injuries.
Case ReportAfter a work-related high-voltage electrical injury, a 40-year-old male working as a welder was transferred to our burn care center. While working, he accidentally touched a wire with his left hand. He was subsequently thrown from the source. The patient was alert, oriented, and hemodynamically stable on arrival at the hospital. He had 40% visible total body surface area burns involving the trunk, left lower extremity, and bilateral forearm and hands, including 3rd-degree burns to the left arm and left leg, which were entry and exit points. He had unproportionate pain in his left lower extremity. Capillary refill of the left foot was regular. Compartment pressure was measured as 5 mmHg, 16 mmHg, and 10 mmHg for the left leg's anterior, posterior, and lateral compartments, respectively. The arterial and venous system of the left lower extremity was reported as a patent after Doppler ultrasonography. Besides, he presented with myoglobinuria (>12,000.0 ng/mL) and a creatine kinase of 21,297 U/L, and thus, copious intravenous hydration and sodium bicarbonate infusion were begun. His electrocardiogram, brain computed tomography (CT), upper and lower abdomen CT revealed no pathology. Intravenous piperacillin/tazobactam at 4.5 g every 8 h was started empirically after a consultation with a specialist in infectious diseases for antimicrobial management.
At presentation, the patient had a 1 cm wide, circumferential, full-thickness burn in his proximal phalanx of the fourth finger and an eschar formation at the second metacarpal head level on the palmar side. The capillary refill and sensation of the finger were intact. On the 3rd day, several bullae on the ring finger and brisk capillary refill were observed. A vertical relaxation incision was made at the white eschar. On the 6th day, thrombosed dorsal veins of the ring finger were seen. Capillary refill was getting faster, and the finger started to have bluish color compatible with venous insufficiency. Enoxaparin 4000 IU was started twice daily. Two medical leeches, Hirudo medicinalis, were used every 2 h for 3 days. 500 mg ciprofloxacin two times a day was started as an empirical treatment to avoid spreading infection from medical leeches. Finger circulation was dependent on the leeches for 3 days. Finger circulation was deteriorated gradually and wholly lost on the 10th day of the injury [Figure 1]. Ray amputation was performed after total demarcation of the finger, and the stump was closed primarily. The patient was referred to the psychical therapy after discharge from the hospital. The late-term image is demonstrated in [Figure 2].
DiscussionRing-associated burns are an uncommon presentation of burn injuries.[2] The conversion of the electrical current, which is dependent on the voltage of the electrical source and resistance of the body tissues, into the thermal energy causes tissue damage.[3] When high resistance body tissues, bone, tendon, fat, and skin are exposed to high-voltage electricity >1000 V, they tend to heat up and coagulate.[3] Another factor determining the degree of injury is the thermal conductivity of a ring.[3] A higher thermal conductivity value implies that metal can become hotter in a shorter amount of time for a given amount of energy.[3] Gold and silver, which most rings are made of, have high thermal conductivities, resulting in more extensive tissue damage.[3]
Ring burn has a unique injury pattern due to circumferentially. Anatomically, high caliber veins predominantly run along the dorsal aspect of the finger on both the radial and ulnar sides above the proximal phalanx.[4] Further, the dorsal skin is thinner than volar skin, making the finger susceptible to venous congestion in circumferential injury.[5]
In the literature, most cases of ring burn occurred due to low-voltage injuries and resulted in superficial injuries that managed with secondary healing and skin grafting. However, an approach to serious ring burn injury resulting in venous congestion and finger amputation was absent.
In this case, high-voltage electric injury, gold ring, and full-thickness burn that affected the dorsal venous network of the finger are the main factors to develop progressive venous congestion.
Conservative treatment modalities to venous congestion of the finger include systemic heparinization, relaxing incisions on the affected region, topical heparinization, and medicinal leech applications.[6],[7] However, these interventions were insufficient to save the finger in our case.
Therefore, we propose an algorithmic approach to ring burn [Figure 3]. At first presentation, capillary refill and pulse oximeter of the finger should be checked. If capillary refill time is around 2 s and oxygen saturation above 95%, the finger should be followed up closely, and secondary healing with skin grafting might be performed. If brisk capillary refill, dark red blood, and low oxygen saturation are compatible with venous congestion observed, relaxing incisions or dorsal escharotomies should be performed. If venous congestion persists, locoregional flap and external bleeding interventions such as heparin drips and medical leeches might be performed. If slow capillary refill time and low oxygen saturation with a pale finger compatible with arterial insufficiency is detected, relaxing incisions should be performed first. When there is no response to any interventions for venous congestion and arterial insufficiency, urgent revascularization should be considered. Flow-through venous flap and vein grafts might be used as salvage treatments for severe ring burn injuries. Kuo et al. suggested that blood vessels 3 cm beyond the margin of the wound, if they have normal elasticity, intact endothelium with good arterial bleeding, can be used for anastomosis in early-stage electric burn cases.[8] Therefore, vein grafts or venous flaps that bypass the 3 cm margin of the wound might be beneficial to restore the venous network in circumferential electric burn cases. When the revascularization is failed and results in total finger necrosis, then ray amputation of the finger should be performed as a last choice to obtain dexterity, function, patient satisfaction, and cosmetic results.[9]
ConclusionWhile superficial ring burn can be successfully managed with conservative treatment with close follow-up, full-thickness burn with vascular compromise should be intervened with relaxing incisions, escharotomies, locoregional flaps, and external bleeding. In addition, urgent revascularization with flow-through venous flaps or vein grafts should be considered in any doubt of the loss of the finger circulation. The main message we intend to give is that progressive venous congestion and necrosis of the finger in the circumferential electric burn cannot be prevented unless anatomic restoration of the venous system.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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