unfortunately , electrical injury can result in some of the most devastating thermal traumas . as opposed to thermal burns ,
the cutaneous burn size does not correlate with the extent of damage seen in highvoltage ( > 1000 v ) electrical injuries ; electrical injuries result in extensive deep tissue injury in addition to various other systemic complications .
morbidities , prolonged hospital stay , multiple visits to the operating room , and long rehabilitation process are not uncommon with these types of injuries .
a 47 year - old caucasian male , working as an electric company linesman , was transferred to the montreal general hospital following a workrelated high - voltage electrical injury ( hvei ) . while working near high tension power lines , he lost balance and accidently grabbed hold of a wire running 14,000 v with both hands .
he was subsequently thrown from the source , fell approximately twenty feet , and suffered blunt head trauma resulting in loss of consciousness .
he had 3% visible total body surface area burns involving bilateral wrists circumferentially and bilateral hands ( fig .
this consisted of third degree burns to the volar aspects of both wrists , and second degree burns to the dorsal aspects of both wrists and hands with digits and palms relatively sparred .
ct scan of the head revealed a left frontal bone comminuted fracture and a left subdural hematoma with a 3 mm shift . the patient was immediately taken to the operating room by the neurosurgery team for left frontal craniectomy .
images a & b show the volar aspects of the left and right 
 wrists , respectively .
images c & d show the burns extending 
 onto the dorsal surface of the left and right hand , respectively . within hours of presentation
, he was found to have elevated compartment pressures in both hand ( 100 and 70 mmhg on the right and left , respectively ) and wrists ( 91 and 75 mmhg on the right and left , respectively ) and was immediately taken to the operating room for bilateral hand and wrist escharotomies and fasciotomies ( fig .
2 ) . subsequently the patient was taken back to the operating room for serial debridements of necrotic tissue .
imaging had shown extensive tissue necrosis extending from the distal third of the forearm to the level of the wrists bilaterally , involving both extensor and flexor compartments ( fig .
images a & b showing wrist fasciotomy , thenar incisions , 
 and carpal tunnel release of left and right hands and wrists , 
 respectively .
images c & d show fasciotomy incisions on the 
 dorsal aspect of left and right wrists , respectively , as well as the 
 longitudinal metacarpal incisions of the hands .
the 
 image of left forearm demonstrates 
 the extensive non - enhancing 
 muscles from the distal 
 third of the forearm to the 
 level of the wrist suspicious 
 for myonecrosis involving both 
 extensor and flexor muscles . despite escharotomies , fasciotomies and serial debridements the patient 's left hand became progressively congested with poor doppler signals and low o2 saturation within each digit . on postburn
day 16 , 9 days since the last debridement , the hand became cold and did not return blood on pinprick in any of the digits . later that night , the patient was taken to the operating room for amputation of the left hand .
after amputation , the patient was left with significant soft tissue defects to bilateral wrists and hands .
bilateral pedicle groin flaps were used for coverage of the defects as well as to increase vascularity to the region ( fig .
fourteen to twenty - one days after inset of the flaps , the flaps were ready to be separated ; final results are shown in fig . 4b and fig .
image a shows the patient with bilateral pedicle 
 groin flaps attached to bilateral wrists .
the patient remained in hospital for a total of 81 days , 65 of which were spent in the icu .
he was taken to the operating room a total of 7 times for escharotomies , fasciotomies , and serial debridements of bilateral hands and wrists , as well as amputation of his left hand and the necessity of tissue transfers , in the form of pedicle groin flaps , for soft tissue coverage .
his course was complicated by rhabdomyolysis with a creatine kinase level peaking at 52 235 u / l , which was successfully managed with copious intravenous hydration and diuresis .
the patient is currently rehabilitation center , working extensively with physiotherapy for elbow and shoulder mobility .
it is reported that electrical burns constitute between 0.04% to as high as 32.2% of admissions to major burn centers ( 1 , 3 - 6 ) .
mortality rates are significant with these types of injuries , reported in the literature to be as high as 59% ( 1 ) ; the most common cause being secondary to an acute arrhythmia at the scene of the injury(2 ) .
they account for approximately 1000 deaths each year in the united states alone , ranking 5th as the most common cause of occupational deaths ( 3 ) .
electrical burns are most commonly seen in work related injuries and involve mainly young males .
electrical company linesman , electricians and construction workers are especially at risk ( 4 , 5 ) .
sadly , it has been reported that as little as 5.4% of patients suffering a hvei are able to return to their previous line of work ( 2 ) .
this can likely be attributed to the fact that these injuries commonly involve the hands and upper extremity ( 4 , 5 ) .
contrary to thermal burns , high - voltage injuries result in extensive deep tissue damage , extending far beyond what can be predicted by tbsa involved , and resulting in higher rate of complications ( 6 ) . in a case - matched controlled analysis comparing hvei and thermal burns , handschin et al .
( 6 ) found a significantly higher rate of escharotomy/ fasciotomy ( 47% vs. 21% ) , amputations ( 19.1% vs. 1.5% ) , as well as total hospital length of stay ( 44 days vs. 31 days ) in hvei versus thermal burns .
commonly seen with hvei are associated acute injuries which include fractures , head trauma , intra - abdominal injury , renal injury , soft - tissue injury , and acute ocular injury .
associated injuries have been described to occur in 25.1% of hvei ( 5 , 8) .
in addition to associated trauma , patients suffering hvei are prone to various complications as well . in a study involving 202 electrical injuries , neurologic complications , deep muscle involvement , and amputation of extremities
similarly , arnoldo et al . found amputation of extremities or digits and muscle necrosis to be some of the most frequently observed complications , observed in 95 and 68 of the 263 cases of hvei , respectively ( 5 ) .
as presented in our case , myoglobinuria and fasciotomy are also commonly encountered complications . in the current literature , escharotomy /
fasciotomy rates have been described to be as high as 54% ( 7 ) and amputation rates as high as 49.4% ( 2 ) .
furthermore , they had found myoglobinuria and the need for fasciotomy to be independent risk factors for amputation . using an equation derived to predict the probability of amputation ( 8) ,
the prognosis for these patients depends on the degree of the initial insult as well as the severity of any subsequent complications .
early intervention is the goal with resuscitation and aggressive surgery being the mainstay of management . considering that most hvei are work - related , the best way to decrease the morbidity and mortality related to these injuries is prevention . through public education and work safety programs ,
 electrical burns are among the most devastating of burn injuries . 
 high 
 voltage electrical injuries result in extensive deep tissue damage and are associated 
 with multiple complications , long term morbidity , and a high mortality rate . 
 we 
 describe the case of a 47 year - old electric company linesman who suffered a high 
 voltage electrical injury ( hvei ) of 14,000 volts to bilateral hands and wrists managed 
 by the division of plastic and reconstructive surgery at the mcgill university health 
 center in montreal , quebec , canada . 
 his management included multiple operative 
 procedures , including escharotomies , fasciotomies , serial debridements , and bilateral 
 pedicle groin flaps , and amputation of his left hand . 
INTRODUCTION
CASE STUDY
DISCUSSION