Lesiones cutáneas específicas en pacientes con neurosarcoidosis / Specific Cutaneous Lesions in Patients With Neurosarcoidosis

La sarcoidosis del sistema nervioso (neurosarcoidosis [NS]) es poco frecuente, pero puede ser grave y producir secuelas importantes. Analizamos los tipos de lesión cutánea específica en pacientes con NS y su utilidad para el diagnóstico de la enfermedad. De un total de 58, 16 presentaron lesiones cutáneas específicas (27,6%). De ellos, 14 eran mujeres y dos varones (edad mediana 50 años [rango 20-84]), que presentaron 24 tipos de lesiones neurológicas (siete neuropatía craneal, cuatro parenquimatosa, tres meníngea, tres mielopatía, uno hipofisaria, dos hidrocefalia y cuatro neuropatía periférica) y 20 lesiones cutáneas específicas (seis máculo-pápulas, nueve placas, uno lupus pernio y cuatro sarcoidosis de las cicatrices [dos pacientes con máculo-pápulas y dos con placas presentaron también sarcoidosis de las cicatrices]. Las lesiones cutáneas estaban presentes al diagnóstico de la NS en 13 casos. Ante la sospecha de esta enfermedad hay que descartar la presencia de lesiones cutáneas específicas cuya biopsia puede acelerar el diagnóstico. (AU)

Neurosarcoidosis is an uncommon but potentially serious disease of the central nervous system that can cause major sequelae. We analyzed the presence and diagnostic usefulness of specific cutaneous lesions in 58 patients with neurosarcoidosis. Sixteen patients (27.6%) had specific cutaneous lesions (14 men and 2 women; mean age, 50 years [range, 20-84 years]). Twenty-four types of neurological lesions were observed: cranial neuropathy (n=7), parenchymal lesions (n=4), meningeal lesions (n=3), myelopathy (n=3), pituitary lesions (n=1), hydrocephalus (n=2), and peripheral neuropathy (n=4). Twenty types of specific cutaneous lesions were observed: maculopapular lesions (n=6), plaques (n=9), lupus pernio (n=1), and scar sarcoidosis (n=4). These last lesions coexisted with maculopapular lesions in 2 patients and plaques in another 2. Specific cutaneous lesions were present at diagnosis of neurosarcoidosis in 13 patients. Recognition of specific cutaneous lesions in a patient with suspected neurosarcoidosis is important as biopsy can accelerate diagnosis. (AU)

[Translated article] Specific Cutaneous Lesions in Patients With Neurosarcoidosis / Lesiones cutáneas específicas en pacientes con neurosarcoidosis

Neurosarcoidosis is an uncommon but potentially serious disease of the central nervous system that can cause major sequelae. We analyzed the presence and diagnostic usefulness of specific cutaneous lesions in 58 patients with neurosarcoidosis. Sixteen patients (27.6%) had specific cutaneous lesions (14 men and 2 women; mean age, 50 years [range, 20-84 years]). Twenty-four types of neurological lesions were observed: cranial neuropathy (n=7), parenchymal lesions (n=4), meningeal lesions (n=3), myelopathy (n=3), pituitary lesions (n=1), hydrocephalus (n=2), and peripheral neuropathy (n=4). Twenty types of specific cutaneous lesions were observed: maculopapular lesions (n=6), plaques (n=9), lupus pernio (n=1), and scar sarcoidosis (n=4). These last lesions coexisted with maculopapular lesions in 2 patients and plaques in another 2. Specific cutaneous lesions were present at diagnosis of neurosarcoidosis in 13 patients. Recognition of specific cutaneous lesions in a patient with suspected neurosarcoidosis is important as biopsy can accelerate diagnosis. (AU)

La sarcoidosis del sistema nervioso (neurosarcoidosis [NS]) es poco frecuente, pero puede ser grave y producir secuelas importantes. Analizamos los tipos de lesión cutánea específica en pacientes con NS y su utilidad para el diagnóstico de la enfermedad. De un total de 58, 16 presentaron lesiones cutáneas específicas (27,6%). De ellos, 14 eran mujeres y dos varones (edad mediana 50 años [rango 20-84]), que presentaron 24 tipos de lesiones neurológicas (siete neuropatía craneal, cuatro parenquimatosa, tres meníngea, tres mielopatía, uno hipofisaria, dos hidrocefalia y cuatro neuropatía periférica) y 20 lesiones cutáneas específicas (seis máculo-pápulas, nueve placas, uno lupus pernio y cuatro sarcoidosis de las cicatrices [dos pacientes con máculo-pápulas y dos con placas presentaron también sarcoidosis de las cicatrices]. Las lesiones cutáneas estaban presentes al diagnóstico de la NS en 13 casos. Ante la sospecha de esta enfermedad hay que descartar la presencia de lesiones cutáneas específicas cuya biopsia puede acelerar el diagnóstico. (AU)

Application of Artificial Dermis Combined With a Medial Flap From the Second Toe to Repair Degloving Injury of the Fingertip.

There is no standard technique for repairing degloving injuries of the fingertip. Nail bed flap transplantation is a common surgical technique to address this injury, but this procedure inevitably damages the donor site in the toe. This article describes a surgical technique that can restore the appearance of the injured fingernail and preserve the length and function of the injured finger without damaging the toenail.

Honey dressing for penile skin avulsion caused by traditional circumcision: a case report.

OBJECTIVE: Penile skin avulsion is a rare complication of circumcision but commonly encountered as the result of traditional practice. We aimed to present the use of honey dressing and the benefit of its wound healing properties for management of such a complex wound. CASE: A 24-year-old male patient with penile bleeding presented to the emergency department after undergoing traditional circumcision. Complete degloving of the penis with active bleeding and foul odour, along with heavy contamination of chewed betel leaves and powdered amoxicillin was found. Honey (Madu Nusantara, PT. Madu Nusantara, Indonesia) was used as dressing after copious irrigation using saline and povidone-iodine with bleeding control. RESULTS: Honey dressing was shown to be effective for secondary wound healing of such a complicated and contaminated wound-in this case due to its antimicrobial, anti-inflammatory, immunostimulatory and autolytic debridement properties. A complete re-epithelialisation of the wound was achieved without progression to the hard-to-heal state by day 43. Suboptimal sexual function and aesthetic result due to wound contracture were observed as surgical reconstruction via split-thickness skin graft was refused due to cost. CONCLUSION: In this case report, honey dressing was shown to be effective for wound healing, even in a penile avulsion with complete skin loss and heavy contamination. In rural settings, where penile avulsion due to traditional circumcision is common, honey should be considered as one of the dressing choices.

Effect of ethanolic extracts from Piperaceae leaves on the reduction of skin necrosis and wound healing in an animal model of degloving injuries.

PURPOSE: To assess the effect of the ethanolic extract of the leaves of three species of plants from the Piperaceae family on reducing necrosis and enhancing wound healing in an animal model of degloving injuries. METHODS: The animals were divided into six groups, each consisting of six animals: sham, negative control, EEPA (Piper amalago ethanolic extract), EEPG (Piper glabratum ethanolic extract), EEPV (Piper vicosanum ethanolic extract), and positive control receiving hyperbaric oxygenation. The animals underwent surgery to induce excision wounds, and the extent of cutaneous necrosis was evaluated using graphic software, while wound healing was assessed through histopathology. RESULTS: Skin necrosis percentage area was: sham group = 62.84% 6.38; negative control group = 63.03% 4.11; P. vicosanum = 40.80% 4.76 p < 0.05; P. glabratum 32.97% 4.01 p < 0.01; P. amalago = 32.40% 4.61 p < 0.01; hyperbaric oxygenation = 33.21% 4.29 p < 0.01. All treated groups showed higher collagen deposition and less intense, plus predominantly mononuclear inflammatory infiltrate, suggesting improved healing process. CONCLUSIONS: The three tested extracts demonstrated efficacy in reducing the extent of cutaneous necrosis caused by degloving injuries and also showed evidence of improvement in the wound healing process.

Cervico-thoracic Morel-Lavallée lesion.

Morel-Lavallée lesions (MLLs) result from high-energy trauma causing separation of subcutaneous tissue from the underlying tissue, most commonly in the gluteal region or thigh.We report the case of a woman in her 40s with a fluctuant collection of the cervico-thoracic region following trauma. Further imaging identified an MLL. An orthoplastic approach resulted in non-operative management with a spinal brace. Three months from initial injury, the lesion completely resolved. She was symptom free at final follow-up and discharged.We present the only recorded case of MLL developing in the cervico-thoracic region. Management posed difficultly as no literature currently exists. We demonstrated conservative management for cervico-thoracic MLL can be effective.We have described the first documented case of cervico-thoracic MLL. MLL is not exclusive to pelvic injuries and can develop in the cervico-thoracic region. We have shown conservative management is a viable treatment of atypical MLL.

Traumatic Degloving Wounds Treated With Low Continuous Wall Suction Drainage: A Novel and Effective Technique to Prevent Recurrence.

Soft tissue degloving wounds overlying fractures present a technical surgical challenge and have a high rate of recurrence. Despite several current treatment methods, there remains a need for improved therapies to address this complex issue. The purpose of this study was to introduce a novel technique for managing soft tissue degloving wounds in the setting of fractures requiring operative fixation. Eleven consecutive patients with soft tissue degloving wounds overlying operatively managed fractures were treated with our novel technique for "dead space" elimination in the peri-operative period. The technique entails placing Jackson Pratt drain(s) within the degloving wound during operative debridement and placing them to low continuous wall suction postoperatively. This patient series shows that the application of 40 to 60 mm Hg of negative pressure allows for thorough drainage of the hemolymphatic fluid collection and elimination of dead space, allowing the delaminated tissue layers to heal together and preventing recurrence. [Orthopedics. 2023;46(4):e257-e263.].

Arterialization of plantar venous system via vein graft: A novel technique for reconstruction of heel pad degloving injuries.

BACKGROUND: Patients with heel pad degloving injury frequently develop ischemic necrosis of the area, necessitating soft-tissue reconstruction surgery. We have developed a technique for arterialization of the plantar venous system via vein graft (APV) as the primary revascularization treatment. The objective of this study was to clarify both the utility of APV for the preservation of degloved heel pads and the impact of this preservation on clinical outcomes. METHODS: Ten consecutive cases of degloving injury with devascularized heel pad were treated at a single trauma center from 2008 to 2018. Five cases underwent APV and five underwent conventional primary suture (PS) as the initial treatment. We evaluated the course according to the frequency of heel pad preservation, additional intervention after heel pad necrosis, post-operative complications, and outcomes using the Foot and Ankle Disability Index score (FADI) at the time of last follow-up. RESULTS: Among the five cases that underwent APV, the heel pad was preserved in three cases and flap surgery was required in two cases. All cases that underwent PS developed necrosis of the heel pad, requiring skin graft in one case and flap surgery in four. One skin graft case and one free flap case after PS developed plantar ulcers. The three cases with preserved heel pads exhibited higher FADI than the seven cases that developed necrosis. CONCLUSION: APV showed a relatively high frequency of heel pad preservation, which otherwise was uniformly lacking. Functional outcomes were improved in cases with preserved heel pad compared to those that developed necrosis and underwent additional tissue reconstruction.

Amputación vs. salvataje: Enfoque Ortoplástico. Acerca de un caso / Amputation vs. salvage: Orthoplastic Approach. Case report

Introducción. Los cirujanos ortopédicos y plásticos trabajaban por separado cuando se enfrentaban a casos reconstructivos desafiantes que involucraban la reconstrucción del tejido blando y esquelético. Cirugía Ortoplástica es el nombre dado a la asociación de Cirugía plástica y ortopédica. Objetivos. Describir el Enfoque Ortoplástico en traumatismos masivos de miembros y su importancia en el abordaje multidisciplinario de pacientes. Material y método. El presente es un estudio descriptivo retrospectivo, en el cual se describe un caso con una lesión masiva de miembro inferior, en el Parque de la Salud, Posadas, Misiones, Argentina, entre febrero y mayo del 2022. Reporte de caso: Se presenta un caso de una paciente femenina de 24 años de edad con lesión masiva por desguantamiento de extremidad inferior derecha producto de accidente en vía pública al ser arrastrada debajo de una unidad de transporte público. Discusión. El salvamento de la extremidad y la amputación temprana con soporte protésico son las dos modalidades empleadas para las formas extremas de traumatismo de la extremidad inferior, con poca claridad en cuanto a lo que el paciente debe esperar en términos de resultados de calidad de vida. Conclusión. La decisión de amputar o salvar una extremidad es compleja. Los cirujanos ortopédicos y plásticos involucrados en esta atención deben tener una comprensión clara del papel del otro y la importancia de cada uno para una buena resolución. Esto es lo que llamamos el Enfoque Ortoplástico de la cirugía reconstructiva de las extremidades.

Introduction. Orthopedic and plastic surgeons worked separately when faced with challenging reconstructive cases involving skeletal and soft tissue reconstruction. "Orthoplastic Surgery" is a name given to the Association of Orthopedic and Plastic Surgery. Objectives. Describe the Orthoplastic Approach in massive limb trauma and its importance in the multidisciplinary patient approach. Material and Method. This is a retrospective descriptive study, in which a case with a massive lower limb injury is described, in the Parque de la Salud, Posadas, Misiones, Argentina, between February 2022 and May 2022. Case Report. A case of a 24-year-old female patient with massive injury due to dismantling of the right lower extremity as a result of an accident on public roads when she was dragged under a public transport unit is presented. Discussion. Limb salvage and prosthetic supported early amputation are the two modalities employed for extreme forms of lower extremity trauma with little clarity as to what the patient should expect in terms of quality of life outcomes. Conclusion. The decision to amputate or save a limb is complex. The orthopedic and plastic surgeons involved in this care must have a clear understanding of each other's role and the importance of each for a good resolution. This is what we call the "Orthoplastic Approach" to reconstructive surgery of the extremities

Experiencia en el manejo y tratamiento de lesiones tipo degloving en el Centro Nacional de Quemados, Montevideo, Uruguay / Experience in the management and treatment of degloving injuries at the National Burn Center, Montevideo, Uruguay

Introducción. Las lesiones tipo degloving o avulsiones extensas de partes blandas representan un desafío para el equipo médico tratante. Es fundamental el adecuado manejo de estos pacientes dada la alta morbilidad. Objetivos. Estudio de las lesiones tipo degloving de partes blandas tratados en el Centro Nacional de Quemados, su manejo y tratamiento en los últimos 18 años. Analizar la situación actual de estas heridas a fin de proporcionar herramientas para el desarrollo de estrategias de prevención y tratamiento. Materiales y métodos. Estudio retrospectivo período enero 2004 - enero 2022, análisis de base de datos del Centro Nacional de Quemados del Hospital de Clínicas, Montevideo, Uruguay, incluyendo todos los ingresos por degloving extensos de partes blandas Resultados. La población estuvo compuesta por 38 pacientes, en su mayoría con lesiones por siniestro de tránsito (92,1%) en rol peatón (57,9%). Se encontró una tasa de complicaciones de 55,3% y una mortalidad de 15,8%. Se vio asociación entre complicaciones infecciosas y mortalidad y entre cultivo positivo al ingreso y demora en el ingreso al centro de quemados. Conclusiones. Las lesiones graves de miembros inferiores se han presentado con elevada tasa de mortalidad y de complicaciones infecciosas. Estas complicaciones se asociaron con un mayor tiempo de internación. Las complicaciones infecciosas a su vez se asociaron con la mortalidad, igual que la extensión lesional.

Introduction. Degloving injuries or extensive soft tissue avulsions represent a challenge for the medical team. Proper management of these patients is essential given the high morbidity. Objectives. To study of soft tissue degloving injuries treated at the National Burn Center, their management and treatment in the last 18 years. To analyze the current situation of these injuries in order to provide tools for development of prevention and treatment strategies. Materials and methods. Retrospective study from January 2004 to January 2022, database analysis of the National Burn Center of "Hospital de Clínicas" (Montevideo-Uruguay), including all admissions for extensive soft tissue degloving. Results. The population consisted of 38 patients, mostly with injuries due to traffic accidents (92.1%) of which 57.9% were pedestrians. A complication rate of 55.3% and a mortality of 15.8% were found. An association arised between infectious complications and mortality and between a positive culture on admission and a delay in time to enter to the National Burn Center. Conclusions. Lower limbs severe injuries have presented a high rate of mortality and infectious complications. These complications were associated with a longer hospital stay. Infectious complications, in turn, were associated with mortality, as well as the extent of lesions.

Negative pressure therapy in a scenario of distal femur fracture with internal degloving injury.

Internal degloving injuries are commonly seen in the pelvis. Similar lesions in the distal femur are rare. They cause a separation between the subcutaneous layer and deep fascia, which results in blood, lymph, necrosed fat and fluid collection in the space. They result in infection and soft tissue complications. Treatment options include conservative management with compression dressings, percutaneous aspiration, mini-incision drainage and sclerodesis. Here we describe a case of closed internal circumferential degloving injury of the distal thigh with a distal femur fracture treated by an innovative technique involving negative pressure therapy, internal fixation of the fracture and secondary skin grafting.

Fingertip degloving injury coverage with homodactyle bipedicled dorsal island flap.

OBJECTIVES: To investigate the curative effect of repairing digital degloving with flaps from the bilateral dorsal branch of the proper digital artery of the same finger. MATERIAL AND METHODS: Twenty-three patients with fingertip degloving injury treated with flaps from the bilateral dorsal branch of the proper digital artery of the same finger in our hospital from February 2020 to March 2022 were retrospectively included. Active finger range of motion, cold intolerance, pain on visual analogue scale and patient satisfaction were evaluated. RESULTS: There were 3 cases of flap blister and 2 of vascular crisis after the operation, all of which healed after symptomatic treatment. All the other flaps and skin grafts survived. Follow-up ranged between 6 and 25 months (mean, 13.8 months). The skin flap was full in shape and soft in texture. Incidence of cold intolerance was low in the palmar flaps and dorsal flaps, and finger range of motion recovered well. The technique relieved pain, and patients were satisfied with the results. CONCLUSION: Flaps from the bilateral dorsal branch of the proper digital artery of the same finger were effective for repair of fingertip degloving. The technique easy to implement, and can repair large defects; the repaired finger shows good function and appearance.

Clinical application of an expanded reverse-island flap with two dorsal metacarpal arteries and dorsal metacarpal nerves in index- and middle-finger-degloving injury repair and amputation reconstruction.

The dorsal metacarpal artery flap (DMAF) is irrefutable as an effective way of repairing long finger defects, and hand surgeons might consider using it for long finger reconstruction or degloved injury repair. Unfortunately, the DMAF containing a single dorsal metacarpal artery (DMA) hinders the treatment effect. The sensory restoration of long fingers and the reconstruction of phalangeal joints and tendon grafts are unsolved challenges as well. We reported our experience in reconstructing the index and middle finger by a reverse-island flap with two DMAs and dorsal metacarpal nerves (DMNs) with blood supply. We reviewed ten patients with finger-crush injuries affecting eight index fingers and two middle fingers. Degloving injuries occurred in two patients, and finger amputations occurred in eight others. Two patients received simple flap reconstruction, and eight received finger reconstruction, including seven from abandoned phalangeal joints and tendon grafts of the severed finger and one from the iliac crest bone graft. All patients underwent finger reconstruction by an expanded reverse-island flap consisting of two DMAs and DMNs up to a maximal size of 9 × 8 cm2. Postoperative follow-up evaluation showed a satisfactory appearance and functional recovery of the reconstructed fingers. We posit that the expanded reverse-island flap involving two DMAs and DMNs constitutes a feasible and safe option for restoring a severely damaged index or middle finger, particularly for patients who are unwilling to undergo toe-to-finger transplantation to reconstruct the injured long fingers.

Reconstruction of an Octogenarian Major Pretibial Degloving Injury Utilizing Negative Pressure Wound Therapy and Subsequently Combining Fenestrated-Type Artificial Dermis Without Skin Grafting.

Major pretibial degloving injuries are complex wounds, which can be challenging to treat. Despite recent advances in reconstructive options, most of these injuries still require a prolonged healing period and may result in amputation. Few reports have been published on the management of these complex traumatic injuries. In this article, we present a case of an octogenarian, frail patient with a major pretibial degloving injury. Treatment included serial surgical debridements in combination with negative pressure wound therapy aimed at salvaging the avulsed tissue. Subsequently, a fenestrated-type artificial dermis and negative pressure wound therapy were used as combined therapy so as to obtain adequate soft tissue coverage. The patient made an unremarkable recovery and was discharged on day 22 after injury. The wound healed by secondary intention without need for skin grafting.