Treatment dilemma: conservative versus surgery in cutis aplasia congenita.

Cutis aplasia congenita (CAC), a congenital absence of skin and its appendages, may extend into underlying muscles and bones. The scalp is the commonest site and it may be associated with acrania. CAC presents either as a thin transparent membrane, a black eschar, an ulcer or a healed scar. The dilemma of either immediate surgical management or conservative treatment is much more pronounced in the presence of acrania. Two patients with scalp lesions measuring 12 x 8 cm and 14 x 12 cm respectively and one patient with 4 cm wide circumferential trunk cutis aplasia treated conservatively are presented. The conservative treatment is simple, easy to carry out, and effective even for large defects; therefore, it is recommended in cutis aplasia congenita till complete healing. Surgical interventions such as tissue expansion and resurfacing, contracture release, etc. are for the correction of subsequent deformity at a later date.

Expansion technique for skin grafts (Meek technique) in the treatment of severely burned patients.

The important limiting factor in the treatment of the severely burned patient is the lack of autograft donor skin. The method of obtaining uniform widely expanded postage stamp autografts described by Meek in 1963 has been evaluated in this study amongst seven severely burned patients. The expansion ratio of 1:4, 1:6, 1:9 was mostly used. After the removal of polyamide gauze on seventh post-operative day the autografts island were covered with overlay allograft, if the expansion ratio of 1:6 and above was used. The mean epithelialization rate was 90% within 4-5 weeks. The preliminary experience suggests, and proves that, it is a method of choice in severely burned patients.

Acute thrombocytopenic crisis following burns complicated by staphylococcal septicaemia.

The pathophysiological changes in a burn patient can at times manifest as severe complications, the management of which can be extremely challenging to the burn surgeon. A case report of an adult male with burns (18% total body surface area) who developed an acute unexpected thrombocytopenia crisis (2x10(9) l(-1)) on day 3 followed by disseminated intravascular coagulation is presented. The various etiological factors and possible mechanisms leading to thrombocytopenia in burns are discussed. Minor burns may present acute major complications in the presence of other thrombocytopenic factors like trauma and sepsis and thrombocytopenia by it self can be a good indicator of sub-clinical infection.

Staphylococcal septicaemia in burns.

This study analyses staphylococcal septicaemia in a series of 1516 burn patients who were admitted to the burn unit of the Al-Babtain Centre for Burns and Plastic Surgery, Ibn Sina Hospital, Kuwait over a period of 6.5 years (1 June 1992-31 December 1998). One hundred and nine patients (7.2%) developed clinically and microbiologically proven septicaemia, of which 80 (73.4%) showed one or the other type of Staphylococcus in their blood. Fifty (62.5%) of them were males and 30 (37.5%) females, with a mean age of 26 years and the mean total body surface area of burns (TBSA) of 45% (range 1-93%). Preschool age children comprised 27.5% of the patients. Flame was the dominant (80%) cause of burn. Of the 80 patients who had 91 episodes of septicaemia, 52 (65%) had MRSA, 8 (10%) MSSA, 11 (13.8%) MRSE and 5 (6.2%) MSSE and 4 (5%) others had mixed organisms. Only the patients with MRSA had multiple episodes. Eight patients (10%) showed septicaemic episodes within only 48 h of admission; however, the majority of the patients (77.5%) had a septicaemic attack within 2 weeks postburn. Of the 52 MRSA septicaemic cases, 39 (75%) survived and 13 (25%) died. Four patients with septicaemia due to mixed infections died. A total of 19 patients were intubated, 14 due to inhalation injury and 5 because of septicaemia; all in the former group died. Glycopeptide therapy (vancomycin/teicoplanin) was instituted immediately following the detection of staphylococci in the blood. No significant difference was noted in relation to mortality amongst the septicaemic patients, whether or not on prophylactic antibiotic. Fifty-six (70%) of the 80 patients had 139 sessions of skin grafting and survived. Of the 52 MRSA patients, 40 had 101 sessions of skin grafting and 33 of them survived. The apparent low mortality was probably due to early detection of the organism, appropriate antibiotic therapy, care for nutrition and early wound cover. This study indicates a high incidence of staphylococcal septicaemia (especially due to MRSA) in the burn unit. A surface wound is the likely source of entry to the blood stream in these immunocompromised patients. The organism could be detected in blood as early as 48 h postburn and in as little TBSA burn as 1% in this MRSA endemic unit. Inhalation injury with major burns and added staphylococcal septicaemia invariably proved to be fatal.

Liquid ammonia injury.

The toxic effects of a gas depend on the time of exposure, concentration and its chemical nature. Pressurized liquids and gases exert an additional cold thermal injury and this may complicate the clinical picture. A patient who had an accidental exposure to liquid ammonia over a prolonged period, manifesting in cutaneous, respiratory and ocular damage in addition to a severe cold thermal injury (frostbite) with a fatal outcome is presented. The patient had flaccid quadriparesis and episodes of bradycardia, which has not been reported previously. These manifestations raise the possibility of the systemic toxicity in patients with prolonged exposure to ammonia.

Burn mortality during 1982 to 1997 in Kuwait.

The study group is comprised of 234 patients (6.4%) who died out of 3680 patients treated for burn injuries during the period January 1982 to December 1997 in Kuwait. There were 112 (47.9%) males and 122 (52.1%) females and their mean age was 30 years (range 1-93) when compared with 24 years among survivors. The high mortality amongst two age groups 0-5 years (39 deaths, 16.7%) and 16-35 years (109 deaths, 46.6%) shows their vulnerability in the society. In 190 patients (81.2%) the burn injuries occurred at home. A total of 216 patients (92.3%) sustained flame burns mainly due to clothes on fire (40.6%) and cooking gas accidents (25.2%), and in 18 patients (7.7%) the burns were due to scalds. The suicidal burns occurred in 22 female and 5 male patients mainly of younger age groups. The mean percentage of burns was 71% (range 9-100%) as against 20% amongst survivors, and 195 patients (83.3%) had > or = 50% total body surface area (TBSA) burn. Four patients (1.7%) had superficial dermal burns, 94 (40.2%) had full thickness and 136 (58.1%) had mixed with full thickness burns predominance. The associated inhalation injury was diagnosed in 132 patients (56.4%). A total of 61 patients (26.1%) had either single or multiple pre-existing diseases and 51 of them sustained flame burns. The day of death varied from 1 to 103 days (mean 16 days) but 58 patients (24.8%) died within 48 hours of post burn. A total of 120 patients (51.3%) died due to septicaemia, 83 (35.5%) due to renal failure, 28 (10.2%) due to multi-organ failure, and 7 (3.0%) due to bronchopneumonia. The overall mortality rate was 6.4%, but this has significantly lowered to 4.4% (p = < 0.01) during last four years probably due to better burn care. The study thus shows that age group 0-5 and 16-35 years, domestic accidents, flame burn, inhalation injury, and pre-existing diseases are risk factors and septicaemia as the dominant cause of death in our patients.

Pseudomonas aeruginosa septicaemia in burns.

Out of 1415 patients treated as inpatients at Al-Babtain Center for Burns and Plastic Surgery, Ibn Sina Hospital, Kuwait spanning over a period of 6 years from June 1992 to June 1998, 102 developed clinically and microbiologically proven septicaemia. Only 15 out of them had either single or multiple episodes of septicaemia due to Pseudomonas aeruginosa and were studied during their stay in the hospital. Five of them were males and 10 females, with a mean age of 26 years (range 3-51 years) and mean total body surface area of burns (TBSA) of 66% (range 25-90%). All of them had flame burns and resuscitation was found to be difficult in eight patients either due to delayed hospitalization or accompanied inhalation injury. Seven patients were intubated, four due to inhalation injury and three for septicaemic complications. Among the 15 patients under study, a total of 36 septicaemic episodes were detected of which 21 were due to P. aeruginosa. This organism was found in the first episodes in nine patients, in second episodes in six, in third episodes in three and fourth, fifth and sixth episodes in one patient, each at a variable postburn day. Ten patients had 38 sessions of excision and skin grafting, six of them survived. Nine of the 15 patients under study died due to septicaemia, but only six of them had P. aeruginosa as the last isolate. Except for one, all patients had > 40% TBSA burn, two had difficult resuscitation and four were intubated. The day of death varied between 3 to 52 days postburn (mean 19 days). This study showed that females with flame burns are susceptible to P. aeruginosa septicaemia. Difficult resuscitation and intubation also proved to be important risk factors. Septicaemia could occur quite early in the postburn days and the mortality due to this organism was quite high. Early excision and grafting with other effective management may result in a better outcome.

Rifampicin as an adjunct to vancomycin therapy in MRSA septicaemia in burns.

Rifampicin has been successfully used as an adjunct to vancomycin therapy in several clinical conditions of MRSA infections such as endocarditis, ventriculoperitoneal shunts and septicaemia. However, very little information is available in the literature regarding its use in MRSA septicaemia in burns. The present prospective study was conducted to evaluate the efficacy of rifampicin as an adjunct therapy in burn cases with MRSA septicaemia not responding well to vancomycin. Fourteen out of 36 MRSA septicaemia patients with burns who either did not or only partially responded to therapeutic doses of vancomycin within 5-6 days were treated with rifampicin as an adjunct therapy (600 mg, i.v., o.d) for 5 days during the study period between January 1995 to December 1998. All the patients had burns due to flame and the TBSA varied between 20-90% with a mean of 64%. Eleven patients had deep and three had mixed burns. MRSA septicaemic episodes usually followed 2 3 days of detection of the organism in burn wounds. All the isolates were sensitive to vancomycin with an MIC of < or = 1.0 mg/L and were treated with vancomycin, (500 mg, i.v., 6 hourly). The serum vancomycin levels in all the patients were within the therapeutic range. However, blood cultures still remained positive even after 5-6 days of therapy. Institution of rifampicin, as an adjunct to vancomycin therapy to which the MRSA isolates were susceptible, showed a dramatic clinical response and survival of grafts. Thirteen patients survived and one died who had 70% deep burns and blood cultures revealed a multiresistant Acinetobacter in addition to MRSA. The present study thus confirms the efficacy of clinical use of rifampicin as an adjunct in vancomycin nonresponding cases of MRSA septicaemia in burns.

Beta-haemolytic Streptococcus infection in burns.

Group A beta haemolytic Streptococcus has been one of the most serious infections in the burn patients resulting in severe cellulitis and sepsis. Penicillin has been used ever since its introduction as prophylaxis against these conditions. Penicillin prophylaxis was used in our burn unit as well without any serious evaluation until December 1992. This prospective study was therefore, undertaken to evaluate the incidence of beta haemolytic Streptococcus infection in burn patients, and its clinical outcome over a period of 5 years in the absence of prophylaxis with penicillin. 14 of the 1213 burn patients admitted to the Al-Babtain Centre for Plastic Surgery and Burns from January 1993 to December 1997 had either colonization or infection with Streptococcus spp. Their mean age was 15 years (range 1 month to 52 years) and the mean burn surface area was 20% (range 5 to 90%). Streptococci were isolated from burn wounds in 10 patients, throat in 3 and blood culture in 1. Group A Streptococcus was found in 5, group C in 3 and group D in 6 patients. In all patients except one the organisms were isolated > or =72 h post burn. The infections were successfully controlled by antibiotic and no detrimental effect was observed either on wound healing or skin graft take. There was no mortality amongst these 14 patients. The study showed that only 1.1% of the burn patients in our unit acquired Streptococcus of which only one third comprised of group A. This study thus demonstrates that the practice of penicillin prophylaxis during the first five post burn days may not be of any value and therefore, deserves discontinuation in units where the incidence of this organism is minuscule.

Burn septicaemia: an analysis of 79 patients.

Out of 943 patients treated from June 92 to May 96 at the burns unit of the Al-Babtain Centre for Plastic Surgery and Burns, Kuwait, 280 (30%) required admission to the burns intensive care unit (ICBU) and were studied retrospectively. Seventy-nine (28.2%) developed clinically and microbiologically proven septicaemia. Forty-four (56%) were males, 35 (44%) females with a mean age of 26 years (range 45 days to 75 years) and mean total body surface area burn (TBSA) of 46% (range 10-90%). Sixty-two had flame burns, 16 a scald and one had an electric burn. These 79 patients had a total of 118 septicaemic episodes. Sixty (76%) had only one and 19 (24%) had multiple episodes of septicaemia. Fifty-four (68%) had their first episode within 2weeks, though the maximum number of episodes was between 6 and 10 days postburn. Septicaemia was also observed in 13% of patients within 3 days postburn. Out of the 118 episodes, 48 were due to methicillin resistant Staphylococcus aureus (MRSA), 17 due to methicillin resistant Staphylococcus epidemidis (MRSE), 15 to Pseudomonas, 12 to Acinetobacter, four to Streptococcus, another four to Enterococci, two to Klebsiella, one due to Serratia and 15 to more than one organism. Once the septicaemia was diagnosed appropriate therapy was instituted. Fifty-six (71%) patients had 143 sessions of skin grafting and the mortality was low in operated patients. Twenty-three (29.1%) patients died. The low mortality rate was probably due to factors such as continuous clinical and microbiological surveillance leading to quick detection of aetiology, appropriate antibiotic therapy, care for nutrition and early wound cover. This study suggests that flame burn patients are more vulnerable to sepsis. Onset of septicaemia may be as early as 3 days and commonly within 2 weeks. A surface wound is the likely source of entry to the blood stream. Gram positive organisms are dominant in the aetiology. Early detection and appropriate treatment including wound coverage result in a better outcome.

The distally based superficial sural flap for reconstruction of the lower leg and foot.

We describe our experience with the use of distally based superficial sural flaps for coverage of defects in the lower leg and foot in 21 patients. In 18 patients the flap was successfully transferred, in 2 cases partial necrosis of the flap occurred and 1 flap failed completely. In 18 cases the flap was used as a fasciocutaneous flap and in 3 cases as a fascial flap only. The advantages of this flap are: easy and quick dissection, hence saving operating time, minimal morbidity of donor site and preservation of major arteries of the leg. Although the flap was described as reliable for covering defects around the ankle joint, we have been able to cover defects of the dorsum of the foot distally and up to the mid-third of the tibia proximally.

Unusual development of granulomas on the healing surface of burn wounds associated with MRSA infections.

Ten patients with a mean age of 14.5 years and partial skin thickness burns involving 3-5 per cent body surface areas developed rapidly proliferating tumour-like growths on the surface of their healing wounds within 10-21 days of sustaining the injuries. The number of tumours on every patient was either single or multiple and each increased in size daily. The growths were unique in their fulminating-type fleshy mass, with a consistency varying from soft to firm, absence of purulent material or head, and extension up to the fibrous layer covering the musculatuve. Histopathology was suggestive of granulomatous rather than a suppurative nature of the lesions. Isolation of MRSA from the burn wounds of four cases on the first day of dressing and then from the surface of the tumours of all of them and the excised tissues, as well as from the environment of the dressing room, indicated its involvement in the causation of the growths through contaminations of wounds with a hospital endemic strain while handling or dressing. The organisms were resistant to most antibiotics except vancomycin and teicoplanin. The growths in four cases subsided within 72 h with daily dressing, using an injectable solution of either vancomycin or teicoplanin, while the rest required radical excision and immediate cover with split skin grafts and systemic administration of either of the antibiotics. The wounds healed over a period of 8-10 days.

Treatment of ischial pressure sores with an inferior gluteus maximus musculocutaneous island flap: an analysis of 31 flaps.

We describe our experience with the use of an island gluteus maximus musculocutaneous flap (from its most inferior part) based on perforators from the inferior gluteal artery. The study is based on a series of 27 patients in whom treatment was carried out for 31 ischial pressure sores. Eight patients had postoperative complications in the form of dehiscence of the donor flap site and/or infection. Follow-up ranged from 6 to 32 months. During this period three patients developed recurrent sores which were treated with other flaps. We feel strongly that the use of this flap should be considered as a first choice in the treatment of the mild to moderate size ischial pressure sore. Its advantages include ease in elevation of the flap and the provision of a vascularized bulky flap which also spares the vascular pedicles of adjacent flaps for future use.

Bone reconstruction with a free vascularized fibular graft after giant cell tumour resection.

Free vascularized fibular transfers were used in six patients with extensive bony defects after excision of a giant cell tumour of the distal end of the radius. The results have been satisfactory.

Post Gulf war explosive injuries in liberated Kuwait.

We collected the statistics of the victims affected by explosive injuries in liberated Kuwait during the period March to December 1991. Included were 1679 patients treated at nine different hospitals in Kuwait. As members of a trauma team, we, the plastic surgeons, were involved in the care of 152 victims of explosive injuries admitted at Al-Razi Orthopaedic Hospital. The records of these patients were reviewed in detail and the results were analysed. Of the patients, 58 had penetrating wounds and 94 explosive blast wounds. In all, 69 patients (45.3 per cent) were found to have associated fractures, 8 (5.3 per cent) had vascular injuries and in 10 (6.5 per cent) a nerve was also involved. There were 41 patients (26.9 per cent) who required amputations. The mainstay of surgical treatment was adequate wound excision, skeletal fixation and soft tissue coverage. Split-skin grafts were used in 34 patients, local flaps in seven and free flaps in four. Most patients healed within 2-3 weeks. There were 10 patients with explosive blast wounds who developed infection and needed staged wound excision before providing final coverage.

Electrical burns in Kuwait: a review and analysis of 64 cases.

Sixty-four patients with electrical burns were admitted to the Department of Plastic Surgery, Ibn Sina Hospital, Kuwait during the past 6 years. There were 1202 admissions during this period, the incidence of electrical burns being 5.3 per cent. Sixty-nine per cent of the patients sustained injury from direct contact with live electrical wire, the remaining 31 per cent sustained flash burns. The incidence of low voltage injury was much higher as compared to high voltage. Forty-four per cent of these injuries were not work related. Less than 10 per cent of the body surface area was involved in about 80 per cent of the patients. A total of 65 operations was carried out in 39 patients. Twenty of these patients had repeated debridements until the wound was ready for coverage. All 64 patients survived.

Management of thermal injury in pregnancy--an analysis of 16 patients.

Sixteen patients at various stages of pregnancy suffered burns covering between 10 and 80 per cent of the body surface area. This review highlights the management problems of these patients during the first, second and third trimesters. Only two mothers (both with 80 per cent TBSA burns) died. There were five fetal deaths, three of them intrauterine.

The Chinese forearm flap in reconstruction of the hand.

A Chinese flap, based on the radial artery, has been used in 29 patients who presented with problems of reconstruction in the hand. The merits and complications of this procedure are discussed.

Herpes of a digit.

Herpetic digital infection is being diagnosed increasingly by hand surgeons. A case of herpetic infection of a digit in an eight months old child is described.