Keywords
electric burn - top closure - cable ties
Introduction
Electric burn wounds of scalp not amenable to primary closure following debridement
have traditionally been managed by skin grafts, local flaps, tissue expansion, free
flaps, and closure by secondary intention, but the traditional methods have following
limitations:
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Cause considerable morbidity
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Carry risks associated with lengthy healing time
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Are costly to the patient and
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Aesthetically inferior in comparison to tensionless primary wound closure.
Due to advances in research into the biomechanical characteristics of skin, various
devices for skin stretching and secure wound closure have been reported in literature
including Hirschowitz device,[1] Wisebands,[2] the TopClosure 3S system,[3] the EASApproxi device,[4] the shoelace technique,[5] and the DermaClose system.[6] Except for the shoelace technique, the devices mentioned are expensive and beyond
reach of a poor person in a developing country.
We hereby present our experience with use of cable ties as a top closure system that
is effective, easily applicable, readily available, and inexpensive.
Case Presentation
A 27-year-old male presented to us with alleged history of high-tension electric burn
to the scalp. He gave history of loss of consciousness. There was no history of ENT
bleeding, seizures, or vomiting. He was taken to a local setup where he and the wound
were managed conservatively for 20 days before referring to us. On examination, the
patient was conscious and oriented with stable vitals. There was a 10 × 7 cm irregular
wound over the frontal region of scalp ([Fig. 1]). The bone was exposed and purulent discharge was noted. The exit wound was noted
in the right sole and was healing well.
Fig. 1 Wound at presentation.
Pus was sent for culture and sensitivity for initiation of appropriate antibiotics.
Flap coverage for the scalp wound was advised but was denied by the patient due to
financial reasons. Taking inspiration from use of Ty-Raps in closure of fasciotomy
wounds by Govaert and van Helden,[7] a similar modality of treatment was proposed to the patient. After taking valid,
informed, and written consent, preparations were made. Cable ties were procured and
sterilized using ethylene oxide. Cable tie units were prepared consisting of two cable
ties, one of which was secured to the wound margins using nylon 3-0 suture and the
other tie was passed from the pointing end of the first tie in such a manner that
it could move only in a single direction over the integrated gear rack, leading to
wound closure ([Fig. 2]).
Fig. 2 Cable tie system.
After wound debridement, multiple such units were fixed 2 cm from the wound margins
at an interval of 2 cm from each other ([Fig. 3]). The units were tightened daily till wound edge approximation was achieved in a
week ([Figs. 4] and [5]). The units were left in place for another week and were then removed after noting
wound healing. Two months following the procedure, patient presented with adequate
wound healing with an acceptable scar and noticeable hair growth ([Fig. 6]).
Fig. 3 Cable tie fixation to wound margins.
Fig. 4 Wound edge approximation.
Fig. 5 Wound edge apposition.
Fig. 6 Follow-up at 2 months.
Discussion
Cable ties are basically nylon tapes with an integrated gear rack and a small case
with a rachet at one end. Once the other end of the tie has been pulled through the
case past the rachet, it can only be pulled tighter due to the gear rack. Therapeutic
use of Ty-Raps has been reported as early as 1976[8] and has since been used for the internal fixation of (periprosthetic) femur fractures[9] and even anal fistula.[10]
Like other top closure devices, it makes use of creep and stress relaxation for enabling
wound closure. The advantages of using cable ties are as follows:
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Easy availability
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Low cost (Rs 130 for a bundle of 100)
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No ischemia, necrosis, or donor site morbidity
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Avoidance of alopecia, thus more aesthetic
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Allows gradual wound closure allowing simultaneous management of infection and regular
wound toileting.
Thus, cable ties may be considered as a viable alternative to available skin expansion
systems in resource-poor settings.
Further studies are needed to thoroughly evaluate this system for wounds of different
varieties and sites.
