Second-Degree Burn From a Grounding Pad of Surgical Device During Surgery of Left Clavicle Fracture – Untoward, Unexpected Event

Dear Editor, Electrocautery, crucial for controlling bleeding and tissue dissection, can pose a burn risk if not carefully managed. Originating with Joseph River in the 19th century and evolving through Franz Nagelschmidt’s and Doyen’s advancements, modern electrosurgical devices use high-frequency currents to cut and coagulate tissue. Despite these advances, burns can occur, as illustrated by a case involving superficial burns from a grounding pad. This article explores the complexities of such burns and emphasizes preventive measures.[1] We report a case of superficial burns related to the grounding pad following electrocautery. We discuss the intricacies of intraoperative burns caused by electrocautery and aim to create awareness to prevent these hazards. A 40-year-old female presented with a left clavicle fracture. A surgery for open reduction with plating was planned. While consent was obtained for the surgery, specific information regarding the risk of electrical burns from the use of electrocautery and the grounding pad was not included in the consent form. The surgery was performed under regional anesthesia. Before the start of the procedure that involved the use of electrocautery, the grounding plate was placed between the surgical table and the posterior interscapular region. The operation time was one hour. When removing the surgical drapes and the grounding pad, it was seen that a burn injury had occurred at the pad site. Cutaneous examination showed skin necrosis with bulla formation on the interscapular mid-back area confined to the site of the grounding pad [Figure 1a and b]. The bullae were drained with a sterile needle and treated with topical antibiotics and collagen [Figure 2]. Regular follow-up was advised. The burn injury resolved with pigmentation without scar formation.Figure 1: (a) Photograph of the burn site post-procedure on the day of surgery showing skin necrosis and bullae formation confined to the site of the grounding pad on the mid-back interscapular area. (b) Photograph of the grounding pad used during surgery that caused the burn injuryFigure 2: The burn site after bullae drainage and collagen applicationElectrosurgical techniques, which have evolved from ancient practices using heated stones for hemostasis, now rely on advanced diathermy machines developed from Bovie’s innovations. Modern devices use high-frequency currents to minimize electrical shock risks. In monopolar mode, current flows from the active electrode through the patient and returns via the grounding pad, whereas in bipolar mode, current passes directly between electrode prongs, eliminating the need for a grounding pad. Approximately 80% of electrosurgical complications occur during surgery, with only 0.5% related to equipment issues.[2] Iatrogenic injuries can result from direct contact burns, grounding electrode burns, heating of pooled solutions, or circuit-induced burns outside the operative field. Grounding pads are essential for safely returning current to the electrosurgical unit, using metal to ensure low resistance. The fire triangle concept—comprising a heat source, fuel, and oxidizer—highlights the potential fire risks in an operating room, emphasizing the need for careful management of electrosurgical equipment. In our case, a burn at the grounding pad site resulted from a loose connection, causing heat and sparking. Issues such as improper placement can lead to skin reactions or severe burns. A lack of understanding among paramedical staff about the electrosurgical circuit exacerbates these risks. To mitigate burn injuries, strict adherence to electrosurgical protocols is essential. Risks also increase if the grounding pad is placed on high-temperature areas, hairy regions, bony prominences, scar tissue, or moisturizer-covered skin.[3] The common electrosurgical equipment-related intraoperative complications include burns from faulty grounding pad connections or improper placement and accidental burns from overheated or malfunctioning electrodes.[4] To prevent burns from electrocautery, surgeons should ensure proper grounding pad application, ideally securing it with a crepe bandage. A firm contact area of at least 70 cm² is crucial, and the pad’s position should be rechecked during position changes to avoid reducing the contact area, which increases burn risk. To minimize the risk of burn injuries during electrocautery, the grounding plate should be placed on a large, well-vascularized area of clean, intact skin, ideally away from bony prominences and areas with scar tissue or excessive hair. Proper placement ensures a large contact area and effective current dispersion.[5] The latest grounding plates incorporate advanced conductive adhesives and materials designed to minimize burn risks. These pads feature improved conductivity and secure adhesion, significantly reducing the chances of burns during electrosurgery.[6] Understanding and implementing these preventive measures, along with ongoing education and adherence to best practices, are key to minimizing intraoperative burns and ensuring safer surgical outcomes. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.