Discussion:
Total scalp rupture is a serious injury because of its devastating
effect on both the patient’s general health and aesthetics. However,
this type of injury is considered to be of a rare occurrence and could
mostly be encountered during industrial or high-speed road accidents.
Our case had a ruptured scalp extending to the temporal and frontal
bearing skin, the nasal bridge, and left ear’s auricle due to an
electric bike accident.
Most avulsed-scalp-related injuries are associated with hypovolemic
shock and facial trauma. Despite that no signs of hypovolemic shock were
clinically observed, prophylactic fluids administration was still
ordered in emergency settings.
In most similar injuries, a sole or combined injury of blood vessels
could be encountered. This includes superficial temporal artery,
supraorbital artery, occipital artery, and facial artery. These are rich
arterial and venous arcades in the subcutaneous layer above the
epicranial aponeurosis [4][5]. Therefore, these injuries should
be treated first to evade the possibility of developing any surgical
contraindication. Fortunately, we found no similar injures as our case
showed an acceptable patient’s general condition. She was fully awake,
self-aware, and there were no signs of secondary injuries.
Usually, due to the extensive blood supply to the scalp, hemorrhaging of
the scalp may appear profuse and should always raise suspicion of
intracranial and cervical damage. Thus, patients should be examined
thoroughly during the secondary survey by taking cervical spine and
brain computed tomography to all patients in order to exclude surgical
contraindications. As indicated in this case, test results proved no
signs of cervical nor intracranial damage.
Surgical replantation is the optimal treatment of the avulsed scalp that
was first described by Miller et al in 1976 [6]. A successful
replantation can well restore the hair-bearing aesthetic unit that is
irreparable by other types of reconstruction [7]. Many surgical
techniques were used for managing these types of skin defects usually
depending on the defect size including microvascular surgery, skin
grafts, and free flap techniques. Free flap techniques allow for
reliable wound closure while providing a variety of reconstructive
options. The most common flaps that are used to cover the scalp are
radial forearm flap, latissimus dorsi free flap, serratus anterior flap,
and anterolateral thigh flap [7].
Another method is presented by KHANDELWAL et al. (a successful use of
hyperbaric oxygen therapy for a complete scalp degloving injury)
[8], discussed a case of a 43-year-old female who presented with a
complete scalp degloving injury, the result of a tractor powered
take-off that caught her hair, after initial evaluation and
stabilization, the patient underwent a microsurgical replantation
procedure after 4 hours of her injury and lasted for 4 hours, during the
procedure Only the superficial temporal arteries were re anastomosed
with no venous anastomosis possible due to the extent injury of the
scalp, the surgeons then administered Hyperbaric oxygen (HBO2) treatment
at 2.5 atmospheres absolute (ATA) for 90 minutes after surgery due to
duskiness of the flap, further HBO2 treatments were administered and a
post-operative leech therapy for 10 days. At one-year follow-up the area
of granulation tissue was reduced, with no detectable hair growth or
nerve function. KHANDELWAL et al. showed in their case that the use of
(HBO2) therapy could increase the chances of tissue survival.
The main reason we went for full-thickness graft is the lack of proper
equipment at our hospital. Microvascular surgery, free flaps, or HBO2
therapy were all out of reach. Despite that, grafting appears to have
great results when certain indications are considered.
Declarations
•Ethics approval and consent to participate
Ethical approval was given by the Aleppo University Hospital and the
parent’s patient has given their Parental consent for this study
•Consent for publication
Written informed consent was obtained from the patient’s parent for the
publication of this case report and any accompanying images. A copy of
the written consent is available for review by the Editor of this
journal.
•Availability of data and material
All data generated or analyzed are included in this article
•Competing interests
No conflict of interest exits in the submission of this manuscript.
•Funding
There were no funding
•Authors’ contributions
all authors have read and approved the manuscript
MBA : Lead in writing and reviewing the manuscript
SS, AH, AA, AN, BZ, AE :Contributed in writing the manuscript.
•Acknowledgements
Our sincere thanks to all the doctors and nurses who participated in the
treatment of this case, and we also thank the patient’s parents for
allowing us to reports this case.