The entity of thermal-crush-avulsion hand injury (hot-press roller burns) treated with fast acting debriding enzymes (nexobrid): literature review and report of first case.

Hand burns are present in >60% of all burn cases and in fire mass casualty incidents even up to 100%. Most trauma and especially burns may be detrimental to the complex and delicate structures of the hand by direct injury, indirect BICS (Burn Induced Compartment Syndrome and interstitial high pressure) or by delayed or faulty treatment. BICS represents a special threat as the increasing swelling and oedema of the small diameter hand and forearm will exert pressure on the capillary/venous system, eventually ending in irreversible damage to the skin, nerves, muscle and vascular bed. Immediate release of constricting skin by incisional escharotomy and sometimes fasciotomy may arrest this vicious cycle: escharotomy is simple for experienced hand or burn surgeons, but they are not always present at the primary treatment site. The diagnosis of BICS is not simple either, as the direct measurement of interstitial/compartment pressure is rarely done. Burns caused by hot rollers such as industrial linen ironing machines are especially traumatic as besides the "simple" thermal burn, the hot rollers exert immense crushing pressure to the hand caught between the rollers. Over the last few years, several publications have described the role of a newly approved Bromelain derived enzymatic debriding agent (NexoBrid) for burns in general and hand burns in particular, and its ability to resolve or prevent BICS. We present a rare severe thermal/crush hand injury case where we were able to successfully treat the patient with NexoBrid enzymatic debridement-escharotomy.

Une atteinte des mains est observée dans plus de 60% des brûlures, et dans quasiment tous les cas de catastrophes. La plupart des traumaitismes, en particulier les brûlures, peuvent être délétères pour les structures complexes et délicates de la main. Ceci peut être dû à la brûlure elle même, à un syndrome compartimental (SC), à un traitement tardif ou mal conduit. Le SC est particulièrement dangereux dans les espaces ténus de l'avant bras et de la main. L'augmentation de pression consécutive à l'oedème obère la microcirculation, entraînant au bout du compte des lésions cutanées, nerveuses, vasculaires et musculaires irréversibles. La libération immédiate des tissus ainsi comprimés par incision de décharge cutanée voire aponévrotomie peut interrompre le cercle vicieux. Il s'agit d'un geste simple pour des chirurgiens spécialisés, malheureusement pas toujours disponibles sur le site du traitement initial. Le diagnostic de SC n'est pas toujours aisé si la mesure directe des pressions tissulaires n'est pas réalisée. Les brûlures dues à des rouleaux chauffés comme ceux des presses à repasser industrielles car, outre le dégagement de chaleur, les rouleaux exercent une pression intense sur la main coincée entre eux. Depuis quelques années, plusieurs articles on décrit le rôle d'un nouvel agent de débridement enzymatique à base de bromélaïne (Nexobrid) pour le traitement des brûlures dont celles des mains ainsi que ses capacité à prévenir et traiter les SC. Nous présentons ici un cas de main de presse avec utilisation, couronnée de succès, de Nexobrid.

Use of the polymerase chain reaction to detect Mycobacterium leprae in urine

Leprosy is an infectious disease caused by Mycobacterium leprae. The polymerase chain reaction (PCR) has been applied to detect M. leprae in different clinical samples and urine seems to be attractive for this purpose. PCR was used to improve the sensitivity for diagnosing leprosy by amplifying a 151-bp PCR fragment of the M. leprae pra gene (PCR-Pra) in urine samples. Seventy-three leprosy patients (39 males and 34 females, 14 to 78 years old) were selected for leprosy diagnosis at a reference laboratory in Maringá, PR, Brazil. Of these, 36 were under anti-leprosy multidrug therapy with dapsone and rifampicin for tuberculoid (TT) and dapsone, rifampicin and clofazimine for borderline (BB) and lepromatous (LL) forms. The control group contained 50 healthy individuals without any clinical history of leprosy. DNA isolated from leprosy patients’ urine samples was successfully amplified by PCR-Pra in 46.6 percent (34/73) of the cases. The positivity of PCR-Pra for patients with the TT form was 75 percent for both patients under treatment and non-treated patients (P = 0.1306). In patients with the LL form, PCR-Pra positivity was 52 and 30 percent for patients under treatment and non-treated patients, respectively (P = 0.2386). PCR-Pra showed a statistically significant difference in detecting M. leprae between the TT and LL forms of leprosy in patients under treatment (P = 0.0033). Although the current study showed that the proposed PCR-Pra has some limitations in the detection of M. leprae, this method has the potential to be a useful tool for leprosy diagnosis mainly in TT leprosy where the AFB slit-skin smear is always negative.

Use of the polymerase chain reaction to detect Mycobacterium leprae in urine.

Leprosy is an infectious disease caused by Mycobacterium leprae. The polymerase chain reaction (PCR) has been applied to detect M. leprae in different clinical samples and urine seems to be attractive for this purpose. PCR was used to improve the sensitivity for diagnosing leprosy by amplifying a 151-bp PCR fragment of the M. leprae pra gene (PCR-Pra) in urine samples. Seventy-three leprosy patients (39 males and 34 females, 14 to 78 years old) were selected for leprosy diagnosis at a reference laboratory in Maringá, PR, Brazil. Of these, 36 were under anti-leprosy multidrug therapy with dapsone and rifampicin for tuberculoid (TT) and dapsone, rifampicin and clofazimine for borderline (BB) and lepromatous (LL) forms. The control group contained 50 healthy individuals without any clinical history of leprosy. DNA isolated from leprosy patients' urine samples was successfully amplified by PCR-Pra in 46.6% (34/73) of the cases. The positivity of PCR-Pra for patients with the TT form was 75% for both patients under treatment and non-treated patients (P = 0.1306). In patients with the LL form, PCR-Pra positivity was 52 and 30% for patients under treatment and non-treated patients, respectively (P = 0.2386). PCR-Pra showed a statistically significant difference in detecting M. leprae between the TT and LL forms of leprosy in patients under treatment (P = 0.0033). Although the current study showed that the proposed PCR-Pra has some limitations in the detection of M. leprae, this method has the potential to be a useful tool for leprosy diagnosis mainly in TT leprosy where the AFB slit-skin smear is always negative.

Two cases of burns in children from French Guinea with oculocutaneous albinism.

Oculocutaneous albinism is an autosomal recessive disorder. It is associated with a disorder in the synthesis of melanin pigment, clearly manifested by the absence of colour in the skin, iris, and hair. In addition to its importance for a person's physical appearance, melanin plays a protective role with regard to solar radiation: its absence exposes the skin to a greater risk of related photogenic injury. The two young patients reported, suffering from oculocutaneous albinism, developed first- and second-degree superficial burns after a few hours of exposure to the sun.

New burns centre in parma hospital, west emilia hub.

Parma Hospital is the Trauma Centre for SIAT (Trauma Patients Integrated Assistance System) in the West Emilia District in the regional trauma patient project. SIAT's goal is to provide the quickest and most appropriate treatment in major trauma patients. Extensive burns are a multi-organ pathology, i.e. a major life-threatening trauma. Our burn patients are treated on the "Hub and Spoke" model: triage and immediate transfer from the Spoke (first- and second-level Centre) to the Hub (third-level centre, i.e. the Parma Hospital Burns Centre). Burn treatment requires pre-hospital care (timely assistance, airways security, steady life parameters, adequate central or peripheral access, fluid administration, maintenance of body temperature, transport) and adequate hospital treatment (fluid resuscitation, pain therapy, gastroduodenal ulceration prophylaxis, escharotomies, and topical wound care).

Reverse fasciosubcutaneous flap versus distally pedicled sural island flap: two elective methods for distal-third leg reconstruction.

In case of soft-tissue injury to the distal third of the leg, a safe and effective repair technique should be adopted. The use of complex procedures such as free flaps and cross-leg flaps is not always advisable. The authors present two methods that have proved to be both reliable and effective in obtaining long-lasting satisfactory results: the reverse fasciosubcutaneous sural flap and the reverse fasciocutaneous island sural flap. Since 1992 the authors have operated on 25 patients affected by traumatic tissue loss of the distal third of the leg and the calcaneal region. They used the fasciosubcutaneous flap in 14 patients and the sural flap in 11. Both of these flaps are technically simple, safe, and effective, and cause minimal injury to the donor site. The sural flaps are more useful for moderate-size wounds, especially in the calcaneal region, whereas the fasciosubcutaneous flap is better for repairing larger lesions of the leg and the ankle.

Myxoma of the maxilla: surgical treatment of an unusual case in a child.

A case of unusual myxoma in a 2-year-old child is reported with its surgical treatment and postoperative outcome. Differential diagnosis with other pathologies such as mucocele and sarcoma is discussed.

Simultaneous reconstruction in severe degloving injuries of the fingers.

The reconstruction of degloved fingers often requires tissue coverage from a distant donor site, transferred to the defect by means of pedicle flaps. The authors propose three main donor areas, depending on the reparative needs of the hand: the contralateral upper limb, the abdomen, and the retroauricular-mastoid region. The reconstruction techniques described in this paper guarantee satisfactory morphological and functional results and are therefore preferred in immediate reconstruction of the fingers following degloving injuries.

Successful treatment of an impressive primary lymphedema of the extremities.

We report the case of an impressive primary lymphedema of the four extremities which did not response to previous conservative and partial surgical treatments and imposed the amputation of both the lower extremities and of the left arm. We have successfully treated the involved right arm by means of radical excisional procedure and skin graft. After five years no recurrence of the disease was observed and morphologic and functional recovery is complete.

[Rehabilitation of burned patients. II. Therapeutic exercise]. / La riabilitazione del paziente ustionato. Parte Seconda: L'esercizio terapeutico.

After illustrating some major ideas concerning disability and the role played by the Rehabilitation Medicine, with particular reference to burns, the Authors consider rehabilitation. The main therapeutical rehabilitation measures used in the various stages of the disease are described. The Authors conclude by underlying the importance of an early and adequate rehabilitation as well as the need for a multidisciplinary approach since patients suffering from burns present a variety of medical, surgical and rehabilitation problems.

Reconstruction of the heel by a medial plantar flap.

Reconstruction of the heel is a complex problem for which many methods have been proposed. The authors describe a method of applying a medial plantar flap with particular reference to special clinical situations of a vascular nature. Based on their clinical experience, they recommended the medial plantar flap as the method of choice in the reconstruction of the heel, particularly in view of the trophic, mechanical and sensory features of the transposed skin and the absence of a significant morphological or functional deficit in the donor site. Moreover, the method involves a single surgical stage and a brief period of hospitalisation.

[Immediate reconstruction of the fingertip in traumatic pathology of the hand. Our clinical experience]. / La ricostruzione immediata del polpastrello nella patologia traumatica della mano. Nostra esperienza clinica.

Significant loss of fingertip pulp is a quite difficult surgical problem: the fingertip, in fact, participates effectively in virtually all hand functions. Following a severe fingertip injury, the restoration of durable, pain-free skin cover is perhaps the most critical factor determining the ultimate functional results. For this purpose several methods have been described. The Authors report their clinical experience in immediate fingertip reconstruction: skin graft, V.Y. advancement flaps, cross-thenar flaps, cross-finger, and distant flaps have been used. These techniques have provided to be useful and extremely reliable in treating acute fingertip injuries: in fact these methods provide sufficient tissue bulk to restore digital length, pulp, contour and nail matrix support.

[Rehabilitation of burned patients. I. General aspects]. / La riabilitazione del paziente ustionato. Parte prima: Aspetti generali.

The authors discuss the general aspects of problems connected with pathology caused by burns from a rehabilitation standpoint. The motivations that render all the rehabilitation effort more and more important for assisting the patient suffering from burns are reported. Then, brief considerations follow regarding the physiopathologic aspects of the healing process evolution. The authors also report about the main functional deficiencies caused by the pathologic involvement of the motion as well as of the respiratory system.

Expanded tubed flap in scalp reconstruction: a modern option in an old technique.

Reconstruction of extensive scalp defects represents a difficult problem for the plastic surgeon. In this case report, a successful result was obtained by stretching a dorsal tubed flap with an inflatable balloon placed between the tube and the underlying donor site. This modified tissue expansion has permitted us to transfer an adequate amount of tissue and resurface an extensive area hardly reached by other reparative methods.

Tissue expansion in the leg: limits and complications in trauma pathology.

Subcutaneous tissue expansion in the treatment of skin loss was first introduced by Neuman (1957) and subsequently developed by Radovan (1982) as a means of increasing the amount of tissue available for reconstruction. It takes advantage of the elasticity of the skin and its ability to expand when submitted to traction, thereby increasing its surface area. This is achieved by the temporary subcutaneous insertion of prostheses which are gradually expanded with physiological saline injected percutaneously through a valve. Once the required increase in skin surface has been achieved, the prosthesis is removed. Indications and modalities for the use of expanders in the head and neck (Argenta et al., 1983; Manders et al., 1984) and the breast (Radovan, 1982; Argenta et al., 1983) are now well established, but severe skin loss in the distal part of the leg, particularly if due to trauma and accompanied by exposure of the neural structure, may create serious problems of reconstruction. We therefore found it useful to apply this new technique in this situation, having previously adopted it in other parts of the body and obtained good results which would have been difficult to achieve with traditional techniques.

[Familial malignant melanoma and its relation to dysplastic nevus syndrome: considerations on 6 clinical cases]. / Melanoma maligno familiare e i suoi rapporti con la sindrome del nevo displastico: considerazioni su 6 casi clinici.

Two cases of familial expression of malignant melanoma are presented, with regard to three patients recently operated on for this neoplasm. The authors review the literature existing on this subject and make important comments about some hereditary factors probably predisposing to malignant melanoma; among these characteristics are the pigmentary traits of skin, adnexa and iris, the so-called "dysplastic" or "atypical" moles, the cutaneous sensitivity to the sun.

[Frontal and naso-mental island flaps in partial loss of nasal substance--advantages and disadvantages]. / I lembi ad isola frontale e naso-genieno nelle perdite di sostanza parziali del naso--vantaggi e svantaggi.

The authors illustrate the frontal and naso-labial island flaps for reconstruction of loss of substance of the nose, comparing them with the more usual rotation flaps and discussing their advantages and disadvantages. Regarding the advantages: the satisfactory aesthetic result immediately after the operation, the oncological excision and the complete reconstruction in only one surgical step, the valid vascular support with sure vitality of the flap and the elegance of the surgical technique. Among the disadvantages: the limited rotation arc, the excessive bulk of the frontal flap for the reconstruction of the internal canthus, the frequent "trap door" effect, the possible relief in the area of the subcutaneous tunnel and the more laborius surgical intervention.