1649 - Shocking Outcome: Atypical Peripheral Nerve Deficits following Electrical Burn by Train Rail

Case Diagnosis: A 25-year-old male with no significant medical history presented after sustaining an electrical injury when his phone fell onto a transit rail. He grasped the device, was shocked, and lost consciousness. He was intubated in the field but extubated upon arrival to an outside hospital. Examination revealed ~4% TBSA full-thickness burns involving bilateral upper extremities, anterior torso, and right leg (Figure 1). Neurological exam showed bilateral upper extremity weakness and sensory loss. Impaired flexion and extension of digits, as well as sensory deficits of the dorsal and palmar region of the first, second, and third digits in an unconventional pattern were present in the left upper extremity. The right upper extremity regained slight flexion in all digits besides the second, and mild abduction/adduction function.
 

Case Description: Initial trauma workup with CT head, cervical spine, chest, abdomen, and pelvis was negative except for possible upper pulmonary contusions. Labs demonstrated rhabdomyolysis, which improved with fluid resuscitation. Due to evolving erythema, antibiotics were escalated from Ancef to Unasyn and vancomycin. The patient underwent tangential excision and coverage of nonviable burn tissue.
 

Discussions: Electrical burns often track along neurovascular structures, causing tissue necrosis and peripheral nerve injury. In this case, deficits in wrist and digital motion implicate the median (flexion and thumb opposition), ulnar (intrinsic hand strength), and radial (wrist extension) nerves, suggesting multifocal injury from brachial plexus through distal branches. Early EMG/NCS helps distinguish plexopathy from peripheral neuropathy. Burn rehabilitation emphasizes ROM to prevent contracture, while splinting supports weakened grasp and extension. Close integration of surgical wound care and neurorehabilitation preserves function.
 

Conclusions: Multidisciplinary management including Plastic Surgery, Infectious Disease, and Rehabilitation was coordinated to address would care and brachial plexus–related deficits. Early physical and occupational therapy promoted earlier-than-expected functional recovery.