Salvage of shoulder joint through simplification of wound management.

Infection is a common sequela of open dislocation of the shoulder joint. This typically leads to joint surface and humeral head necrosis, resulting in severe limitation of motion. Few cases of open and infected glenohumeral joints have been reported, and none had a good functional outcome with pain-free, near-full range of motion. Here we report the case of a 24-year-old man, who sustained a severe degloving injury of his left shoulder with an open glenohumeral joint, in a road traffic accident. We describe a treatment plan that salvaged near-full range of shoulder motion and resulted in pain-free active and passive movements.

Surgical Burden of Traumatic Lower Limb Amputations in the Pediatric Age Group.

Although the burden of traumatic lower limb amputation (TLLA) has been well described when it concerns the adult population, there is an evident scarcity in literature concerning this matter in the pediatric population. Our objective is to review the surgical burden and long-term outcome of lower limb amputation among pediatric trauma victims who have experienced lower extremity amputation as the result of an accident or injury. A PICO format was utilized. The population of interest includes only children and adolescents suffering TTLA. The generation of data to be reviewed was executed using MEDLINE and PUBMED. Altogether, all data that includes trauma in the pediatric population in the timeframe 1949-2019 was revised and yielded 13 observational studies. This systematic review includes statistical comparisons between the group of interest of this review and the adult population. Other comparisons include those between the different sources. Our outcomes include a consistent pattern. This consistency between different studies was opposed by certain contradictions. Disparity between the different reviewed studies was displayed in terms of the distribution of the most cited complications of TLLA among different sources and the frequency of additional surgery. The dichotomy in the results of the reviewed studies highlights a gap in the data relevant to TLLA in the pediatric population. In addition to the discrepancies in the available literature, the significant physio-anatomical differences between the pediatric and the adult populations which are relevant to TLLA highlight a requirement for further studies regarding TTLA in the pediatric age group.

Alors que les conséquences d'une amputation de membre inférieur (AMI) en contexte traumatique ont bien été décrites chez l'adulte, les données manquent chez l'enfant. Nous avons dans ce but réalisé une revue PubMed (1949-2019), à la recherche des conséquences à court et long termes d'une AMI chez l'enfant et l'adolescent. Nous n'avons trouvé que 13 études, observationnelles, aux résultats parfois contradictoires. Les types de complication et la nécessité de reprise chirurgicale étaient aléatoirement retrouvées et semblaient différentes de celles décrites chez l'adulte. Nous avons réalisé une analyse statistique versus AMI chez l'adulte, peu concluante. Cette comparaison difficile entre adultes et enfants ayant subi une AMI, quand les deux populations sont différentes, pointe la nécessité d'études spécifiques concernant l'AMI chez l'enfant.

Rat model of burn wound healing: effect of Botox.

Animal models of burn play a crucial role in studying the mechanisms of burn wound progression and the factors that regulate various stages of healing. In this study, using a rat model, we assessed the effect of Botox in the healing process through parameters like transepidermal water loss (TEWL), histological alterations, transforming growth factor beta (TGF-beta1) and tumor necrosis factor alpha (TNF-alpha). Fifty Sprague-Dawley rats were inflicted with 5 cm2 second degree burn and divided into 2 groups; one group was injected intralesionally with Botox and the other with saline. Daily observation and transepidermal water loss measurement were performed. Biopsies were taken on days 0, 3, 8, 14, and 28 for histology and polymerase chain reaction, testing TGF-beta and TNF-alpha. The results showed no significant difference in TEWL except for slightly better preservation of moisture with Botox. Histology revealed relatively better and faster regeneration with Botox, delayed lower grade inflammation, and increase in fibroblasts. TNF-alpha had an acute increase of 21-fold then tapered down while TGF-beta levels increased on day 3 after TNF-alpha, peaked on day 8 and then started to decrease until complete healing. Botox improved the healing process and the cosmetic appearance of burn scar.

The 2020 Beirut Explosion: A Healthcare Perspective.

On August 4th, 2020, at 6:07pm local time, an explosion took place in Beirut's port near the central district. This tragic event reportedly left more than 204 victims dead, more than 6,500 wounded, and displaced around 300,000 from their homes. Patients were transported to several hospitals, which became quickly overwhelmed within minutes by the large number of patient admissions. This is a retrospective chart review conducted on 292 patients, who presented to the American University of Beirut Medical Center (AUBMC) after sustaining blast-related injuries during the Beirut port explosion on August 4th, 2020. Measures including age, gender, location of the injury, mechanism of blast injury (primary, secondary, tertiary, and quaternary) and outcomes were collected. Time of arrival of the first victim was 10 minutes after the explosion. Patients across all ages presented to the medical center (age range from 3 months to 86 years) and the majority of injuries were in the upper extremity (45.6%), and head and neck region (43.2%). Most blast-related injuries were due to secondary and tertiary types, 78.4% and 24.1% respectively. This study aims to expand the literature and widen the knowledge regarding the mechanism of injury associated with the Beirut port explosion. Moreover, it could be helpful in preparing medical staff, healthcare centers and other communities to work under difficult conditions in similar disasters and improve the global response to devastating events.

Le 4 août 2020 à 18 h 07 locales, une explosion s'est produite dans le port de Beyrouth, à proximité du centre- ville. Cette explosion a tué 204 personnes, en a blessé plus de 6 500 et en a laissé environ 300 000 sans abri. Les blessés ont été acheminés dans plusieurs hôpitaux, vite débordés par cet afflux massif. Cet article est une revue sur dossier de 292 cas de patients blastés lors de cette catastrophe pris en charge à l'Hôpital Universitaire Américain de Beyrouth, la première étant arrivée 10 mn après l'explosion. Nous avons répertorié l'âge, le sexe, la localisation des blessure et le type de lésions de blast (primaire, secondaire, tertiaire ou quaternaire), les plus fréquents étant les blasts secondaires (78,4%) et tertiaires (24,1%) et l'évolution. Les patients étaient âgés de 3 mois à 86 ans et leurs blessures se situaient plus fréquemment au niveau de la partie supérieure du corps (45,6%) ou de la région cervico- céphalique (43,2%). Cette étude permet d'abonder la littérature sur les mécanismes lésionnels après une explosion comme celle du port de Beyrouth. Elle pourrait en outre permettre d'améliorer les réponses médicale, hospitalière et générale après une catastrophe.

End-Of-Life (EOL) Comfort Care And Withdrawal Of Life Support (WLS) Of Severely Burned Patients: A Review Of The Literature.

Ensuring burn patients get appropriate care without pursuing futile treatment has always constituted a challenging balance for burn surgeons. Patients with no prospect of cure who eventually die should potentially experience more comfortable and peaceful end-of-life (EoL) care. Recognizing that death for some patients is inevitable and can only be postponed but not avoided would open the way to a more humane comfort care for such patients. Though comfort EoL services are still not universal in burns intensive care units (ICU) and disparities still exist in access, and use of palliative care appears underutilized, its integration in the burns ICU has increased over the past decade with undeniable benefits. Palliative care consultations should be considered in select burn patients for whom survival is highly unlikely.

Assurer des soins adaptés sans obstination déraisonnable a toujours représenté un équilibre subtil pour les brûlologues. Les patients à qui il ne peut être proposé de traitement curatif mourront et nous devons leur assurer une fin de vie confortable et apaisée. Ainsi, reconnaître que certains patients mourront inéluctablement, un traitement agressif ne faisant que reculer l'échéance, doit nous amener à leur prescrire des soins de confort. La culture des SP semble insuffisamment développée et leur prescription aléatoire au sein des CTB, alors que leur développement dans les décennies passées a indubitablement représenté un progrès. Des consultations de SP au profit des patients au-delà de toute ressource thérapeutique devraient être développées.

From acute management to ultimate reconstruction: a 15-year follow-up of a pediatric patient with necrotizing fasciitis secondary to varicella infection.

Necrotizing fasciitis is a rapidly progressive, life-threatening soft tissue infection. The usually aggressive surgical debridement often leaves disfiguring sequelae.We hereby present the case of a 4-yearold boy who presented with post varicella zoster necrotizing fasciitis over his trunk, and follow his journey post reconstruction with split thickness skin grafts and the sequelae of grafting over the trunk. While the case itself is not unique in its presentation, this is the first report of a long-term follow up, with management of the long-term reconstructive sequelae.

Les fasciites nécrosantes (FN) sont des infections suraiguës graves des tissus cutanés et sous cutanés. Leur traitement chirurgical, fait de débridements agressif, laisse le plus souvent des séquelles délabrantes. Nous présentons ici le cas d'un enfant ayant subi à l'âge de 4 ans une FN du tronc consécutive à une varicelle, au long de son parcours de reconstruction par greffes et sur ces greffes. Bien que ce cas soit initialement non exceptionnel, c'est la première fois que la reconstruction est présentée.

Effect of denervation on burn wound healing.

The skin is a natural barrier between the interior milieu of the organism and its environment. This barrier has multiple physiological functions and may be affected by an array of pathologies including wounds and burns. The present study aims to determine the effect of the nervous system on wound healing. Specifically, this study tested the effect of denervation by chemical ablation on the burn wound healing process using guanethidine for denervation of the sympathetic postganglionic neurons and resiniferatoxin for denervation of the sensory capsaicin-sensitive fibres. Animals were divided into 8 different groups: (1) control group, (2) sensory denervated and burned, (3) sensory denervated non-burned, (4) sympathetic denervated and burned, (5) sympathetic denervated non-burned, (6) vehicle sensory burned, (7) vehicle sympathetic burned, (8) non-denervated burned. We measured different morphologic and biochemical parameters such as wound surface area, histological alterations and mast cells. In addition, NGF, IL-1ß, IL-6 and IL-8 levels were determined using the ELISA technique. The gross observations, the histological data including mast cell modulation, as well as the molecular data, speak in favour of a significant delay in burn wound healing caused by sensory denervation. On the other hand, results support the positive role of sympathetic denervation in speeding up the healing process. The dual effect of the nervous system on burn wound healing is being documented in an animal model for the first time.

La peau est une barrière naturelle entre le milieu intérieur et son environnement. Elle a des fonctions physiologiques multiples et peut être atteinte par de nombreuses pathologies parmi lesquelles plaies et brûlures. Cette étude a pour but d'évaluer les effets du système nerveux sur la cicatrisation et plus particulièrement ceux de la dénervation chimique par guanéthidine des neurones sympathiques post ganglionnaires ainsi que celle des fibres sensitives à capsaïcine par résiniferatoxine. Des animaux ont été répartis en 8 groupes : (1) contrôle, (2) dénervation sensitive + brûlure, (3) dénervation sensitive sans brûlure, (4) dénervation sympathique + brûlure, (5) dénervation sympathique sans brûlure, (6) solvant de résiniferatoxine + brûlure, (7) solvant de guanéthidine + brûlure, (8) pas de dénervation + brûlure. Nous avons mesuré plusieurs paramètres morphologiques et biochimiques parmi lesquels la surface brûlées, les anomalies histologiques et la fonction mastocytaire. NGF, IL1b, IL6 et IL8 ont été mesurés par méthode ELISA. L'observation clinique, les données histologiques dont la modulation mastocytaire ainsi que les données moléculaires orientent vers un ralentissement de la cicatrisation après dénervation sensitive alors que la dénervation sympathique l'accélère. C'est la première fois que ces effets opposés des dénervations sélective est observée chez l'animal.

Refugee camps, fire disasters and burn injuries.

In the past five years, no fewer than 15 conflicts have brought unspeakable tragedy and misery to millions across the world. At present, nearly 20 people are forcibly displaced every minute as a result of conflict or persecution, representing a crisis of historic proportions. Many displaced persons end up in camps generally developing in an impromptu fashion, and are totally dependent on humanitarian aid. The precarious condition of temporary installations puts the nearly 700 refugee camps worldwide at high risk of disease, child soldier and terrorist recruitment, and physical and sexual violence. Poorly planned, densely packed refugee settlements are also one of the most pathogenic environments possible, representing high risk for fires with potential for uncontrolled fire spread and development over sometimes quite large areas. Moreover, providing healthcare to refugees comes with its own unique challenges. Internationally recognized guidelines for minimum standards in shelters and settlements have been set, however they remain largely inapplicable. As for fire risk reduction, and despite the high number of fire incidents, it is not evident that fire safety can justify a higher priority. In that regard, a number of often conflicting influences will need to be considered. The greatest challenge remains in balancing the various risks, such as the need/cost of shelter against the fire risk/cost of fire protection.

Dans les 5 années écoulées, ce ne sont pas moins de 15 conflits armés qui ont propulsé des millions de personnes à travers le monde dans une tragédie et une misère indescriptibles. Actuellement, 20 personnes sont déplacés de force chaque minute en raison d'un tel conflit ou de persécutions, ce qui est une crise historique. Nombre d'entre elles se retrouvent dans des camps de réfugiés de fortune, totalement dépendants de l'aide humanitaire. Les conditions précaires de survie dans ces quelque 700 camps placent ces réfugiés dans une situation de risque non seulement de santé mais aussi de violence physique, sexuelle et mentale (enfants soldats, « recrutement ¼ terroriste). La densité d'habitations installées sans plan est un facteur pathogénique majeur, dans lesquelles les incendies peuvent toucher une superficie très importante. En outre, la dispensation de soins aux réfugiés pose des problèmes spécifiques. Des standard minimums de déploiement ont été édictés au niveau international, mais ils restent largement inapplicables. La prévention des incendies reste une préoccupation secondaire, malgré leur fréquence car il s'agit de trouver une priorité entre la réalisations d'abris sûrs pour dispenser les soins et la prévention des incendies, à coût peu extensible.

Vulnérologie: un néologisme pour magnifier le concept «plaies et cicatrisation¼.

Wound healing, though probably the most critical aspect of essential medical and surgical care, has been neglected for a long time. With the tremendous surge over the last two decades in basic research and in new techniques, wound healing is emerging more and more as a well-defined medical entity transcending existing specialties and subdivisions. Specialists working on the same subject must be known by a common name. There is a need to fill the gap in our current medical nomenclature in order to define all those interested in this subject. With etymologic, semantic and botanical arguments, Vulnerology seems to be an appropriate neologism. It will unite in the same group people who share a common interest and way of thinking to promote the concept of wound healing.

Abdominal compartment syndrome (ACS) in a severely burned patient.

Abdominal compartment syndrome (ACS) occurs when increasing intra abdominal-pressure (IAP) reduces blood flow to abdominal organs. This results in impairment of pulmonary, cardiovascular, renal, hepatic, central nervous system and gastro-intestinal (gi) function, causing multiple organ dysfunction syndrome and death. The significant prognostic value of elevated intra-abdominal pressure has prompted many intensive care units to adopt measurement of this physiologic parameter as a routine vital sign in patients at risk. ACS generally occurs in patients who are critically ill due to any of a wide variety of medical and surgical conditions. it has been recently described as a rare complication of burn injury. it is fundamental to: 1) recognize IAP and ACS; 2) resuscitate effectively; and 3) prevent the development IAP-induced end-organ dysfunction and failure. We present our recent experience with one patient suffering from ACS secondary to burn injury and the physiologic results of abdominal wall escharotomy.

Le syndrome du compartiment abdominal (SCA) se produit lorsque l'augmente de la pression intra-abdominale (PIA) réduit le flux sanguin vers les organes abdominaux. Il en résulte une dépréciation de pulmonaires, cardiovasculaires, rénales, hépatiques, système nerveux central et la fonction (GI) gastro-intestinale, causant le syndrome de défaillance multiviscérale et la mort. La valeur pronostique de la pression intra-abdominale élevée a incité de nombreuses unités de soins intensifs à adopter la mesure de ce paramètre physiologique comme un signe vital de routine chez les patients à risque. Le SCA se produit généralement chez des patients gravement malades en raison d'une grande variété de conditions médicales et chirurgicales. Il a récemment été décrit comme une complication rare associée aux brûlures. Il est fondamental de: 1) reconnaître la PIA et le SCA; 2) ressusciter efficacement; et 3) prévenir le développement de la dysfonction et la défaillance des organes cibles induites par la PIA. Nous présentons notre expérience récente d'un patient souffrant du SCA suite aux brûlures et les résultats physiologiques d'une escarrotomie de la paroi abdominale.

Microsurgery in the burn population - a review of the literature.

The management of patients suffering from burn injury poses unique challenges for the reconstructive surgeon, both in the acute and delayed settings. Once resuscitative measures are optimized and hemodynamic stability is achieved, early burn debridement and coverage is performed. Traditionally, this consists of excision of devitalized tissue and subsequent coverage using split thickness skin grafts. However, in certain instances, and depending on the extent and nature of the burn injury, skin grafting (or even local tissue rearrangement) may not be a reasonable option. in these cases, free tissue transfer may provide a viable reconstructive alternative. While free flap reconstruction is rare in burn surgery, particularly in the acute setting, burn injuries that expose vital structures, such as tendon, nerve, bone, or deep vessels, require robust flap coverage. in the delayed setting, unsightly scar formation and contracture often occurs secondary to skin graft coverage. These significant patient morbidities are often amenable to free tissue transfer as well. This review article discusses the indications, applications, and problems with free flap surgery for burn injuries in both the acute and delayed setting, and summarizes the available literature on microsurgical free tissue transfer for burn management.

La prise en charge des patients atteints de brûlures pose des défis uniques pour le chirurgien de reconstruction, à la fois dans les cadres aigus et retardés. Une fois les mesures de réanimation sont optimisés et la stabilité hémodynamique est obtenue, il faut faire le débridement précoce et la couverture de la brûlure. Traditionnellement, il s'agit de l'excision des tissus dévitalisés et la couverture par division ultérieure en utilisant des greffes de peau partielle épaisse. Cependant, dans certains cas, et en fonction des dimensions et la nature de la brûlure, une greffe de peau n'est pas toujours une option raisonnable. Dans ces cas, le transfert de tissu libre peut fournir une alternative viable. Alors que la reconstruction de lambeau libre est rare dans la chirurgie des brûlures, en particulier dans le cadre aiguë, les brûlures qui exposent les structures vitales, telles que les tendons, nerfs, os, ou les vaisseaux profonds, nécessitent une couverture robuste. Dans le cadre retardé, la formation de cicatrices inesthétiques et de contractures se produit fréquemment secondaire à une couverture de greffe de peau. Souvent ces morbidités importantes sont aussi prêtent au transfert de tissu libre. Cet article de revue discute les indications, les applications, et des problèmes avec la chirurgie de lambeau libre pour des brûlures dans les cadres aigus et retardés. Cet article résume aussi la littérature disponible sur la microchirurgie du transfert de tissu libre pour la prise en charge des brûlures.

Contralateral renal abnormalities in patients with renal agenesis and noncystic renal dysplasia.

The prevalence of contralateral renal abnormalities in noncystic-dysplastic kidney (NCDK) disease and renal agenesis is unknown. Twenty-four patients with NCDK disease and 16 patients with renal agenesis were studied in this 11-year retrospective study. In all patients the urinary system was evaluated by renal ultrasonography, and excretory urography or radionuclide scan. In addition, voiding cystourethrography was performed in 21 of 24 patients with NCDK disease and in 10 of 16 patients with renal agenesis. In those patients where voiding cystourethrography was performed, 14 (67%) patients with NCDK disease and 9 (90%) patients with renal agenesis had contralateral urologic abnormalities. Contralateral vesicoureteral reflux was the most common contralateral abnormality identified in 9 (43%) patients with NCDK disease and in 3 (30%) patients with renal agenesis. It is concluded that contralateral urologic abnormalities are common in patients with NCDK disease and in patients with renal agenesis and that vesicoureteral reflux is the most common contralateral abnormality noted.

Application since 1980 of antihypertensive agents to treat pediatric disease.

Strategies for using antihypertensive agents have changed significantly since 1980. This paper reviews clinical studies devoted to the use of antihypertensive agents in children beyond the newborn period. The availability of converting enzyme inhibitors and calcium channel blockers has significantly improved BP control in children with secondary forms of hypertension. The role of antihypertensive agents to chronically treat primary hypertension in children remains unclear. Additionally, some treatment protocols used in adults that apply to the treatment of hypertensive children and that have been used in the treatment of nonhypertensive disease are discussed. Preliminary studies suggest that the rate of decline of renal function in some forms of progressive renal disease may be retarded by the use of converting enzyme inhibitors.

Extra-adrenal pheochromocytoma.

Extra-adrenal pheochromocytomas, or gangliomas, develop in the paraganglion chromaffin cells of the sympathetic nervous system. They account for 10% of all pheochromocytomas in adults and 30-40% in children. These tumors are usually larger than their adrenal counterpart. The most common site of extra-adrenal phenochromocytomas is the para-adrenal area, but they also occur at the aortic bifurcation, chest, inferior mesenteric and iliac arteries, bladder, heart and brain. In this report, we describe a 13-year-old girl with a pheochromocytoma along the course of the left ureter, a finding which to our knowledge was previously described only once. Clinical presentation, diagnosis, and treatment are similar to adrenal tumors. Patients should be closely monitored with serum and urine catecholamine determination and MIBG scan to detect any recurrence or distant metastasis. Prognosis is usually good if the tumor is detected early to avoid major complications related to catecholamine excess.

Preliminary arteriovenous fistula for free-flap reconstruction in the diabetic foot.

We present our experience at the American University of Beirut Medical Center with two diabetic patients suffering from large necrotic and infected foot ulcers. Both patients were ambulatory at the time of presentation despite their extensive wounds and were believed to have a useful limb with adequate protective sensation worth saving. Below-knee amputation was prevented in both cases by successful soft-tissue coverage of the ulcers using microvascular composite-tissue transfer a few days after performing a preliminary arteriovenous fistula with a long vein graft loop. The flap vessels were anastomosed end-to-end to the arterial and venous limbs of the divided arteriovenous loop. This reconstructive technique of difficult diabetic wounds of the lower extremity, though in two stages, may be safer than one long procedure in a high-risk patient. It is technically easier than long interpositional vein grafts at the same time as free-flap transfer or microvascular anastomoses with small and diseased vessels. It definitely provides more chance of success as larger vessels are used to supply the flap. It permits distension of the vein graft at normotensive physiologic pressures and allows testing the arterial anastomosis as well as the venous flow before final flap transfer. Above all, it allows extreme freedom in performing tension-free anastomoses away from the infected wound.

Necrotizing fasciitis of the upper extremity.

The standard treatment of necrotizing fasciitis is early recognition and early surgical debridement of all necrotic tissues. The use of antibiotics alone does not prove to be effective unless coupled with aggressive surgical treatment. We present a case of necrotizing fasciitis of unknown cause in a child. Although the only treatment was IV antibiotics and fasciotomy without any debridement, the patient survived the disease with minimal morbidity.

Ulnar collateral ligament rupture of the first metacarpophalangeal joint: a frequently missed injury in the emergency department.

Between July 1991 and December 1995, 28 patients elected to consult one of the senior authors for a second opinion or were referred to him by their family physician after being reassured and discharged from our emergency department with the simple diagnosis of "soft tissue contusion" to the thumb. Physical examination and stress radiographs of these patients revealed a missed injury to the ulnar collateral ligament (UCL) of the first metacarpophalangeal joint in 18 patients (64.3%), 12 of whom required surgical repair. Apparently, UCL injuries are frequently underestimated in our emergency department, although the real number is unknown because some patients may have decided to seek further treatment elsewhere. In addition to the numerous trivial injuries that are frequently seen in any emergency department, emergency physicians have the added responsibility of detecting those injuries that require referral to a specialist.

Microsurgical free tissue transfer: a valuable reconstructive procedure--review of 75 cases.

A total of 75 cases of microsurgical composite tissue transfer to reconstruct defects of the head and neck, trunk, upper and lower extremities performed at the American University of Beirut Medical Center between January 1992 and December 1997 were evaluated in a retrospective study. There was a failure rate of 6.6% and a complication rate of 13.3%. Our results show that free tissue transfer can be considered as a safe and viable treatment option in a wide variety of clinical situations including early soft tissue coverage of complex extremity wounds, limb sparing procedures for malignant neoplasms, reconstruction of the head and neck area, treatment of chronic osteomyelitis, and finally reconstruction of the foot in patients with severe diabetic neuropathy and peripheral vascular disease. A brief discussion of the history of microvascular free tissue transfers as well as their value in modern reconstructive surgery is also presented.