burns 41 (2015) 1122–1125
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Feet sunk in molten aluminium: The burn and its prevention David Alonso-Pen˜a a, Marı´a Elena Arna´iz-Garcı´a b,*, Javier Luis Valero-Gasalla c, Ana Marı´a Arna´iz-Garcı´a d, Ramo´n Campillo-Campan˜a c, Javier Alonso-Pen˜a e, Jose Marı´a Gonza´lez-Santos b, Alaska Leonor Ferna´ndez-Dı´az f, Javier Arna´iz g a
Department of Plastic and Reconstuctive Surgery and Burnt Unit, University Hospital ‘Rı´o Hortega’, Valladolid, Spain Cardiovascular Surgery Department, University Hospital of Salamanca, Salamanca, Spain c Department of Plastic and Reconstructive Surgery and Burnt Unit, University Hospital ‘‘Juan Canalejo’’, A Corun˜a, Spain d Infectious Diseases Unit, University Hospital Marque´s de Valdecilla, Santander, Cantabria, Spain e Internal Medicine Department, Hospital ‘‘Virgen del Puerto’’, Ca´ceres, Spain f Centro de Atencio´n Primaria de Noja, Cantabria, Spain g Radiology Department, University Hospital ‘Marque´s de Valdecilla’, Santander, Cantabria, Spain b
Nowadays, despite improvements in safety rules and inspections in the metal industry,
Accepted 7 December 2014
foundry workers are not free from burn accidents. Injuries caused by molten metals include burns secondary to molten iron, aluminium, zinc, copper, brass, bronze, manganese, lead
and steel. Molten aluminium is one of the most common causative agents of burns (60%);
however, only a few publications exist concerning injuries from molten aluminium. The
main mechanisms of lesion from molten aluminium include direct contact of the molten
metal with the skin or through safety apparel, or when the metal splash burns through the
pants and rolls downward along the leg. Herein, we report three cases of deep dermal burns
after ‘soaking’ the foot in liquid aluminium and its evolutive features. This paper aims to show our experience in the management of burns due to molten aluminium. We describe the current management principles and the key features of injury prevention. # 2014 Elsevier Ltd and ISBI. All rights reserved.
Despite safety regulations, the increasing awareness of hazards and the enforcement of safety in foundries, burns from molten metals are still prevalent injuries among foundry workers. Different molten metals have been related with this kind of injuries depending on the nature of the metal. The * Corresponding author. Tel.: +34 923291263; fax: +34 923291263. E-mail address: [email protected]
(M.E. Arna´iz-Garcı´a). http://dx.doi.org/10.1016/j.burns.2014.12.003 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.
properties of aluminium, such as deformability, resistance, and thermal and electric conductivity, give this metal the capacity to be both versatile and useful for industry. However, aluminium can also be a potential agent of severe occupational burns. The aim of this manuscript is to show our experience through three cases of burns caused by molten aluminium. Through a revision of the scarce literature existing concerning
burns 41 (2015) 1122–1125
such burns, we focus on the management and prevention of these occupational and unusual burns.
Materials and methods
Herein, we present three representative cases of burns caused by molten aluminium and their management at our institution: Case 1: A 44-year-old male patient with a previous history of hypertension was admitted to the hospital after an accident in a foundry industry. Prolonged thermal contact with the aluminium alloy penetrated the protective boot and caused a deep burn located at the lateral and dorsal surface of the right foot (3% of the total body surface area) (Fig. 1). The boot was rapidly removed and the patient was transferred to the hospital. Unfortunately, the extent of the burns due to molten aluminium was underestimated, and only conventional care of the wound was initially applied. However, due to worsening of the wound, a plastic surgeon was required and an emergent escharotomy and tissue excision was performed. The wound was covered with a full-thickness mesh skin graft. Local cares were carried out, and the patient was discharged 1 month after surgery. The patient experienced no loss of function in the foot. He had a full recovery and returned to work 4 months after the surgery. Case 2: A 42-year-old male patient, with a previous history of hypertriglyceridaemia and tobacco and alcohol consumption, presented to the hospital with a grade 3 burn due to molten aluminium, which extended over the entire distal area of the right foot (1% of the total body surface area). After the accident, the patients’ boots were removed and he was first bathed in cold water. When the patient was transferred to the hospital, a wound revision was carried out. All peripheral pulses were present and capillary return was normal. The ankle brachial pressure index was performed to assure arterial perfusion of the extremities. The absence of peripheral arteriopathy was determined. A complete debridement of the lesion and coverage with a mesh skin graft was performed. No infection was detected. Two months after admission, a complete epithelialization of lesion was confirmed (Fig. 2).
Fig. 2 – (A) Overview of lesion extending to the distal part of the right foot. It shows the typical scar formation resulting after mesh autologous skin grafts. The skin graft pattern is still visible 1 month postoperatively. (B) Postoperative image 2 months after accident reveals complete epithelization of the lesion.
Case 3: A 24-year-old male patient was admitted to the emergency department with a burn caused by molten aluminium, which spilled into the protective shoe while he was working in the foundry. The patient did not notice the burn initially. After a pain sensation, the shoe was removed and the injury was seen. Cold water was applied and the patient was transferred to the emergency department. He presented a grade 2–3 burn located at the sole of the right foot (Fig. 3). Surgical treatment with excision of the devitalized tissues was performed. Then, skin grafts for covering the cutaneous defect were performed. He was discharged home 10 days postoperatively. The patient achieved complete recovery 6 months after the accident.
Fig. 1 – Extensive third-degree burn covering the dorsal and internal face of the right foot.
Several molten metals have been associated with occupational burns such as iron, steel, manganese, brass, zinc and aluminium. The temperature range of these materials in the foundry process varies from 760 to 1400 8C [1,2]. However, no
burns 41 (2015) 1122–1125
Fig. 3 – Partial-thickness aluminium burn extending to the sole of the right foot. The image makes comprehensible the mechanism of lesion due to spill of the molten aluminium inside the shoe.
correlation exists between the metal temperature and the severity of burns (depth and size of lesions). This is probably due to differences in the purity and nature of each molten metal. Characteristics such as lightness, deformability, endurance and its abundance in nature make aluminium the second most used metal in the modern world. Aluminium is produced from alumina (oxide of aluminium) as a result of an electrolytic reduction process. Refined alumina, obtained from bauxite ore (which contains 60% of alumina in its hydroxide form), is dissolved in a molten bath of cryolite (sodium aluminium fluoride) to 950 8C. Cryolite serves as the electrolyte and, when electric current is passed through the carbon-lined reaction bath, the aluminium metal is liberated. Liquid aluminium has a higher density than the electrolyte, and it is collected at the bottom of the bath. The purity of aluminium is guaranteed by removing silicon, iron and gases. After this process, molten aluminium is carried to the foundry where it is tapped, alloyed and casted into ingots, wires or blocks . It has been reported that burns due to molten aluminium affect mainly male patients, and these are located commonly in the lower legs (85%) with a mean burn size of 2.3% of the body surface area. However, lesions can also affect multiple sites of the body surface: upper extremities, chest, head and neck . During this complex process, and despite the improvements in conditions of safety at work as well as prevention, foundry workers are still likely to suffer burns from molten aluminium. Only a few publications exist on burns due to molten aluminium and their management [4,5]. The magnitude of injury depends directly on the mechanism of lesion . Injury can occur when the molten metal penetrates the leather of the protective garment. Usually, lesions produced with this mechanism are superficial because the high temperature is dissipated in contact with the leather or protective material. Other less frequent and small burns are produced after contact with hot ingots, the overflow of molten aluminium
from the ladle or explosions in contact with moisture . However, the typical mechanisms of lesion due to molten aluminium include metal splashes that penetrate the clothing or a spill onto the shoe, which runs over the skin along the extremity. The aluminium, with no adhesion to the skin, rolls downward along the leg without enough time to burn and create a deep dermal burn in the foot and ankle where the molten metal settles [1,3,7]. Unfortunately, the depth and severity of injuries are not usually recognized at the first moment by industrial clinic physicians or emergency services. A small affected area and an initial lack of pain are causes of misjudging the severity of this kind of burns. These factors lead to a delay in treatment and unexpected complications. An early medical treatment and consultation of a plastic surgeon are warranted and should be guaranteed. As occurs in other burn patients, thromboembolic prophylaxis should be initiated to prevent thromboembolic complications resulting in immobilization and the potential acquired hypercoagulable state sometimes presenting in these patients [8,9]. Additionally, the importance of preservation of the dermis in wound closure caused by molten metals has been demonstrated. The large majority of lesions need an aggressive treatment such as escharotomy, enzymatic debridement or hyperbaric oxygen therapy. An early debridement and prompt coverage are useful mechanisms to avoid complications such as infection or ulceration [10–12]. It provides optimal results and facilitates an early return to work. Amputation is an extreme option, sometimes necessary depending on the burn severity and the patient status. Despite surgical measures, prevention remains the best treatment. Sometimes, foundry workers do not realize the real level of the risk because of the low number of accidents due to molten metals [1,3,4,6,11–15]; however, these lesions can cause great distress, death or sometimes a permanent disability with the consequent high cost for the aluminium industry and sanitary insurances. Despite all prevention strategies carried out during the past decades and the improvement in conditions of safety at work, safety measures can improve further. It is essential to ensure that a suitable protective garment is provided. All safety garments have been designed in order to prevent burns and injuries derived from molten metal industry processes. The protective clothing used is made from different materials, depending on the type of molten metal, and how this material responds to them, the pouring temperature of the metal and the amount of molten metal that workers may possibly be exposed to if an incident occurs [1–3,6]. Besides the composition of the protective garment,all protective clothes should be properly worn by all workers who may be exposed to burns from molten metals. Complete protection of the legs, ankles and feet should be assured by using safety boots or shoes, which avoid the direct contact of metals with the skin. The use of flameproof jackets and pants, gloves, helmets, eye protections, boots, leggings and sweatbands for perspiration is recommended. Coveralls should not normally be provided because they are not easy to remove quickly in case of emergency, and because it has pockets where molten metal may become trapped. The jackets should be large enough to cover the tops of trousers. The
burns 41 (2015) 1122–1125
Fig. 4 – Protective garments for molten aluminium workers.
trousers should be long and wide enough to overlap the top of the footwear (Fig. 4). In addition, all outer garments should be fitted with quick-release fastenings to enable their fast removal in emergencies [13–15].
Despite improvement in conditions of safety at work in the metal refinery industry, burns due to molten metals are still prevalent. A correct medical and surgical management of this kind of lesions avoids morbidity and disability for a prompt recovery. Furthermore, prevention plays a crucial role in the working conditions of foundry workers. A precise education of industry, foundry workers, physicians and insurance companies is necessary to improve diagnosis and provide a definitive treatment. These are clues to reduce patients’ distress, medical expense and disability. Only a few publications on this kind of lesions exist. Through three cases presented in our institution, we describe the main mechanisms of lesion due to molten aluminium, its consequences and its management.
Acknowledgements The authors wish to express their sincere thanks to Dr. Carlos Rodrı´guez Costas, chief of medical services in Aluminio Espan˜ol S.A. (San Ciprian, Lugo), and Dr. Manuel Corredoira Amenedo, chief of medical services in Inespal Metal S.A. (A Corun˜a), for their kindness. We are very grateful to the management of INESPAL Group for providing us with the necessary information.
 Grube BB, Heimbach DM, Engrav LH. Molten metal burns to the lower extremity. J Burn Care Rehabil 1987;8:403–5.
 Himel HJ, Syptak M, Jones Jr KC, Towler MA, Edlich RF. Molten metal burn of the foot: a preventable injury. J Emerg Med 1992;10:147–50.  Margulies DR, Navarro RA, Kahn AM. Molten metal burns: early treatment improves outcome. Am Surg 1998;64: 947–9.  Steiss C. Industrial injuries of the foot. Am J Surg 1958;30:226–71.  Snyder CC, Blocker Jr TG. Injuries to the lower extremities and their significance in industry. Southern Med J 1950;43:574–9.  Das BC, Chaudhury S. Accidents in the aluminium smelting industry. Ind Health 1995;33:191–8.  Boss WK, Arons MS. Molten metal safety boot burns: analysis and treatment. J Trauma 1982;22:884–6.  Sebastian R, Ghanem O, DiRoma F, Milner SM, Price LA. Pulmonary embolism in burns, is there an evidence based prophylactic recommendation? Case report and review of literature. Burns )2014;(Aug). http://dx.doi.org/10.1016/ j.burns.2014.06.018.  Mullins F, Mian MA, Jenkins D, Brandigi C, Shaver JR, Friedman B, et al. Thromboembolic complications in burn patients and associated risk factors. J Burn Care Res 2013;34(3):355–60.  Brown JB. Early care and grafting of acute burns. In: Womack N, editor. On burns. Springfield, IL: Thomas; 1953. p. 121–30.  Kahn AM, McCrady-Kahn VL. Molten metal burns. West J Med 1981;135:78–80.  McCarthy J, Trigger C. High-pressure injection injury with molten aluminum. West J Emerg Med 2014;15(Mar (2)):120–1.  Still J, Law E. Management of a burn sustained as a result of contact with 2400 degrees F molten metal. J Burn Care Rehabil 1994;15(Nov–Dec (6)):523–4.  Lyons C, Healt and safety in the molten metals industry. Health and safe executive. United Kingdom, 11 Aug. 2014. Health and safe executive, Inc.; Available from: http:// www.hse.gov.uk/moltenmetals/.  Dahl C, Aluminized clothing for high heat applications. Chicago, 1 Jan. 2013. Western safety products, Inc.; Available from: http://www.westernsafety.com/ chicagoprotective2013/cp2013pg1.html.