Electric burn of the skull: treatment by applying trepanations and wound dressing. Illustrative case

Abstract

BACKGROUND

Although electric injuries to human tissue are uncommon in contemporary times, their occurrence implies a high degree of morbidity and mortality. These are primarily attributed to the impact of electric current on cellular membranes, resulting in the disruption of ionic changes.

OBSERVATIONS

In this paper, the authors present the case of an electric burn on the skull in a 50-year-old male, treated by utilizing trepanation and daily sterile wound dressing. This approach differs from the conventional treatment involving tissue grafts.

LESSONS

Although the techniques utilized in this case are not commonly chosen as the initial treatment option, they have demonstrated effectiveness. Despite the absence of tissue flaps or grafts, satisfactory coverage of the skull cap was achieved.

Although electric wounds are uncommon in contemporary society, the associated morbidity and mortality are notable despite the low incidence of such wounds. Recent research has indicated that electric burns rank as the fourth leading cause of death resulting from traumatic injuries in the workplace.^1–3 The skull, covered with epithelial and connective tissue, exhibits reduced susceptibility to direct burn injuries.⁴ Epidemiological data reveal a higher incidence among males, with 75% of cases occurring in occupational settings, and the median age of affected individuals being 30.9 years. Nevertheless, exposed and low-income populations are at higher risk for experiencing electric burns, and improvements in socioeconomic factors tend to reduce their incidence.^1,2

Tissue damage resulting from electricity is primarily attributed to the disturbance of cellular membranes, leading to dysfunction in ionic channels and the activation of apoptosis pathways.^5–9 In addition to the electric current, factors such as voltage, intensity, duration, and heat generated while overcoming tissue resistance play a role in the organic injury and can influence the type and extent of the lesion. The collective impact of these factors often requires a considerable number of surgical interventions, giving rise to associated complications.^2,7,8,10

Although electric burns causing full-thickness damage to the scalp are uncommon, they can result in tissue defects that extend to the skull cap, thereby complicating the reconstruction process. In such cases, treatment typically involves debridement of bone and necrotic tissue, often coupled with the use of pediculated grafts. Alternatively, tissue expansion techniques are commonly utilized.^5,11,12 The extent of tissue destruction correlates with the demand for more advanced surgical techniques, often necessitating the use of distant donor areas and microsurgical free grafts.^5,11,12

We present the case report of a male who experienced a severe electric burn injury to the skull, which was treated using an alternative technique that proved to be successful in this situation.

Illustrative Case

A 50-year-old male presented to the emergency department after exposure to an electric current, resulting in extensive tissue burns with skull exposure in the frontal and parietal areas bilaterally (Fig. 1). The current entered through the scalp and, following a vertical course, exited via the left leg. On the day of hospital admission, debridement of the scalp and skull was performed, accompanied by fasciotomy of the left leg.

FIG. 1.

A: Initial aspect of the scalp lesion. B: Resection of devitalized tissue. C: Skull bone after removing devitalized tissue with central bone necrosis. D and E: Burr holes and drilling of necrotic central bone. F: Devitalized tissue removed.

Cerebral angiography was conducted, revealing patency of the superficial temporal artery, suggesting a potential option for a pediculated graft. However, in light of the clinical indications of osteomyelitis, as confirmed by bone culture from the exposed skull bone, the use of a pediculated graft was deemed inadvisable. Instead, the decision was made to create multiple skull cap burr holes, apply daily sterile wound dressings, and perform bedside debridement to facilitate secondary closure. Simultaneously, antibiotic therapy for 8 weeks was initiated to address the osteomyelitis, while tissue gradually proliferated over the burr holes.

Surgical intervention on the skull was conducted 4 weeks after the accident, involving approximately 25 trepanations with superficial diploe exposition in a region previously exposed on the skull cap. Daily application of a sterile occlusive dressing with rayon was implemented, with the objective of promoting the growth of vitalized tissue at the lesion’s edges and over the burr holes. This regimen was maintained for 2 years (Fig. 2). During the hospitalization period, the patient remained conscious with no discernible focal neurological deficits, experiencing progressive improvement, tissue growth, and gradual coverage of the exposed bone. However, 19 months later, a new approach involving debridement and drilling of exposed bone was deemed necessary in an area exhibiting inadequate reepithelialization. After these two surgeries, no additional procedures were needed.

FIG. 2.

Evolution of the injury over 2 years, with daily sterile wound dressings. A: First month after initial surgery. B: Three months. C: Six months. D: Nine months. E: Twelve months. F: Fifteen months. G: Eighteen months (1 month after the second drilling surgery). H: Twenty-four months.

Surgical Technique

Burr holes with a diameter ranging from 1 to 1.5 cm are created in the exposed bone using an electric, gas, or manual burr. Spacing between the holes should be approximately 1.5 to 2 cm, exposing the diploe layer without penetrating the internal table, thus avoiding trepanations in the vicinity of venous sinuses. In the postoperative period, it is imperative to perform daily debris cleaning and maintain bleeding points in the orifices to encourage tissue revitalization. The development of fibrinous and epithelial tissue within the burr holes is noted, along with growth of the lesion’s epithelial tissue edge toward the holes, until eventual closure.

Attention should be directed toward signs of infection, such as purulent secretions, and immediate initiation of antibiotic treatment is warranted if deemed necessary. The time required for complete healing remains uncertain and is contingent upon the individual patient’s progression, hospital care, and the presence of local or systemic infections.

Patient Informed Consent

The necessary patient informed consent was obtained in this study.

Discussion

Observations

The conversion of electrical energy into heat during its passage through tissues can induce direct burning, progressive electroporation, and the rupture of small blood vessels, resulting in ischemia and thrombosis of soft tissues and bones, ultimately leading to necrosis.^5,6,9 Additionally, the irregular shape of the skull predisposes it to the development of epithelial ulcers.⁷ In this context, injuries to the skull and scalp due to electrical burns lack a singular treatment option, and alternative treatments are continually evolving.⁴

The reported patient experienced a complete loss of scalp in both the frontal and parietal regions bilaterally. The widely recommended approach in this scenario involves debridement of bone and necrotic tissue, followed by the application of a well-vascularized flap for coverage.^5,13 In cases with vascular impairment leading to devitalization, removal of the external layer of the skull cap bone is crucial to facilitate granulation. An alternative option is the utilization of local or free flaps to introduce new vessels to the site.^6,12 Moreover, when the injury is confined to the scalp, treatment can be conducted similarly to other burns because in most instances, there is viable tissue for expansion or sufficient vascularization to facilitate grafting.^4,14

However, the utilization of local flaps may not be feasible in severely burned patients because of a limited tissue supply, necessitating the consideration of microsurgical flaps, which have demonstrated safety and yielded satisfactory aesthetic and functional outcomes.^4,15 Myocutaneous flaps and microvascular approaches, along with the application of partial-thickness skin grafts, have facilitated the transposition of large tissue segments and allowed for the transfer of extensive tissue flaps from diverse origins, providing immediate coverage to prevent exposure of the dura mater or brain.^4,7,16 Although debridement was chosen, the degree and extent of tissue injury precluded the possibility of creating a flap or performing a graft. Moreover, it is crucial to ensure that no necrotic bone is retained at the injury site, as it could impede consolidation.⁷ Consequently, we opted for trepanations, exposing the diploe, followed by daily sterile dressing with the aim of promoting the growth of vitalized tissue. This approach was chosen to keep the dura mater and brain unexposed, thus preventing the leakage of cerebrospinal fluid and minimizing the risk of infection.^4,12

In conclusion, the average healing time is reported to be 2 to 3 years for natural healing and 7 months to 1.5 years in patients who have undergone surgery and wet dressing changes.⁶ The patient in our report was considered completely treated after 19 months.

Lessons

Although the techniques utilized in this case are not typically the first treatment option, it had proved to be effective. Satisfactory coverage of the skull cap was achieved even in the absence of tissue flaps or grafts. Consequently, it is suggested that this technique could serve as an alternative treatment in cases in which the use of grafts or flaps is not feasible. Further studies are warranted to refine the reported technique, and an exploration of new dressing methods or an investigation into the potential benefits of hyperbaric treatment after the initial surgery should be considered.

Author Contributions

Conception and design: Neto, Georgeto, Schiavini, Shimoakoishi, Scapin, Marcilio. Acquisition of data: Neto, Shimoakoishi, Santos, Scapin. Analysis and interpretation of data: Neto, Georgeto, Santos, Correia, Scapin. Drafting the article: Neto, Scapin, Marcilio. Critically revising the article: Neto, Georgeto, Lehmann, Schiavini, Santos, Correia, Scapin. Reviewed submitted version of manuscript: Neto, Georgeto, Scapin, Marcilio. Approved the final version of the manuscript on behalf of all authors: Neto. Administrative/technical/material support: Neto, Lehmann, Antonucci, Shimoakoishi. Study supervision: Lehmann. Translation: Correia.