Surgical treatment of the parieto-occipital region extensive scalped wound

In the presented clinical case, we consider the surgical treatment of a 9-year-old girl with an extensive post-traumatic scalp wound in the parieto-occipital region resulting from hair getting into the moving mechanism of a go-kart car and incomplete separation of the scalp in the parieto-occipital region of the head. The early postoperative period (surgical treatment with primary wound closure) was complicated by the development of skin necrosis. An extensive wound defect in the soft tissues of the scalp (up to 150 cm2) was replaced with local related tissues. For this, various methods of plastic surgery were used in different areas of the wound defect: plastic surgery with local tissues, replacement of the defect with a rotated fascio-cutaneous flap and plastic surgery with local tissues using the dosed stretching method. The combined use of these methods made it possible to completely restore full-fledged soft tissues and hair of the injured parieto-occipital region.

Head home: implementation during COVID-19 pandemic

BackgroundRecent research suggests that between 20% and 50% of paediatric head injuries attending our emergency department (ED) could be safely discharged soon after triage, without the need for medical review, using a ‘Head Injury Discharge At Triage’ tool (HIDAT). We sought to implement this into clinical practice.MethodsPaediatric ED triage staff underwent competency-based assessments for HIDAT with all head injury presentations 1 May to 31 October 2020 included in analysis. We determined which patients were discharged using the tool, which underwent CT of the brain and whether there was a clinically important traumatic brain injury or representation to the ED.ResultsOf the 1429 patients screened; 610 (43%) screened negative with 250 (18%) discharged by nursing staff. Of the entire cohort, 32 CTs were performed for head injury concerns (6 abnormal) with 1 CT performed in the HIDAT negative group (normal). Of those discharged using HIDAT, four reattended, two with vomiting (no imaging or admission) and two with minor scalp wound infections. Two patients who screened negative declined discharge under the policy with later medical discharge (no imaging or admission). Paediatric ED attendances were 29% lower than in 2018.ConclusionWe have successfully implemented HIDAT into local clinical practice. The number discharged (18%) is lower than originally described; this is likely multifactorial. The relationship between COVID-19 and paediatric ED attendances is unclear but decreased attendances suggest those for whom the tool was originally designed are not attending ED and may be accessing other medical/non-medical resources

A complex scalp resurfacing utilizing Integra® as temporary dressing in aplasia cutis congenita

BACKGROUND: Aplasia cutis congenita is a rare newborn malformation characterized by focal absence of skin. It possesses difficulty in reconstruction surgery for neurosurgeons and plastic surgeons. We report a challenging case of aplasia cutis congenita who received treatment in our center. CLINICAL CASE: A 2-year-old boy, presented to Plastic and Reconstructive Surgery, Hospital USM, with bilateral vertex defect with encephalocele who received a series of surgical interventions since 1 month old. Unfortunately, he returned after 2 years with a chronic nonhealing scalp wound associated with dura defect and cerebral spinal fluid leakage. The wound was debrided and the swab culture result showed no organism growth. Part of the wound bed with dura defect was repaired using a small piece of transplanted fascia lata and Integra was applied. DISCUSSION: There is scarcity in the medical literature on the reconstructive technique of aplasia cutis congenita. In the case we described here, we successfully managed the wound with multiple application of dermal substitute (Integra) dressing with negative pressure wound therapy and split-thickness skin graft. CONCLUSIONS: Management of aplasia cutis congenita with skull defect remains a controversy. Its management varies depends on its pattern and underlying condition. We successfully develop a new simple method in treating scalp accutilizing Integra.

Post traumatic CSF fistulas – a solved problem?

Objective: To find the frequency of post-traumatic fistulas in acquire data in neurosurgery department of District Hospital Rawalpindi. Study Design: Descriptive Retrospective Study. Setting: Department of Neurosurgery in District Hospital Rawalpindi. Period: July 2017 to 2019. Material & Methods: Total 70 Patients presented with CSF leaks from either ear or nose or scalp wound following head trauma. All these patients underwent treatment in the emergency room because the study of patients included only those to who presented to emergency with head trauma, including some who underwent some surgical procedure as well, apart from the standard conservative management for all patients. Mean and standard deviation of quantitative data (age), was recorded. Categorical data like gender, early and late onset of disease, surgical treatment were expressed in frequencies & percentage. Results: 70 patients including 52(74.2%) male and 18(25.7%) female. The mean ages was 38.34­­+13.21 year. CSF leakage was from nose 33(47%) and ear was 37(53%). At the postoperative period, 8(11%) patients had meningitis and 62(89%) patients had no meningitis. Those patients who treated non surgically as 56(80%) as compared to those who underwent some surgical procedures 14(20%). Majority of the patients 59(84%) had early onset < 48 hours of presentation, while 11(16%) had delayed > 48 hours of CSF leakage. Conclusion: CSF fistulas remain a problem after head trauma, with a significant risk of complications and rarely death, hence requiring prompt diagnosis and careful management. Failure of CSF fistula to heal within an average time of 2 weeks of conservative treatment, usually requires surgical treatment.

Scalp Reconstruction with Novel Unopposing Double Hatchet Flaps- A Case Series

Though there are regional and distant approaches for acquired scalp defect reconstruction, use of local flaps always have the advantage of retaining the topography of scalp. As in treatment of any other defect the choice of a local flap in scalp wound coverage is dictated by the location, size, and depth of the defect and by the availability of adjacent tissue for reconstruction. The versatile and adaptable triangular hatchet flap with a partial skin and subcutaneous bridged pedicle has great versatility. When used singularly or in pair to cover small and medium sized defects, utilising both rotation and advancement components for its movement, has the benefit of maintaining cosmetic appearance. Double hatchet flaps are used commonly in an opposing manner so as to convert a circular wound to a ‘S’ shaped suture line. In the current case series, with a description of four representative cases, authors have presented a modification of this double hatchet flap in unopposing configuration instead of an opposing pattern to cover scalp defects when the type and extent of injury affecting the scalp prevents in heaving flaps at 180 degree to each other. Authors opine that this technique adds into the ever expanding armamentarium of reconstructive surgeon and can be made use of in the aforementioned conditions wherein the standard pattern cannot be employed to cover moderate sized scalp defects.