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Résumé Les traumatismes de la face sont fréquents chez l’enfant et souvent banalisés. La face, très vascularisée, est le siège de saignements impressionnants sur le lieu de l’accident mais souvent sous-estimés chez l’enfant car il existe une vasoconstriction artérielle immédiate très développée. La masse sanguine est de 80 mL/kg chez le nouveau-né, soit 250 mL au total pour atteindre 70 mL/kg à partir de l’âge d’un an. L’évaluation doit être rigoureuse sous peine d’une décompensation brutale. Concernant les plaies, la réparation primaire doit être d’emblée parfaite ou optimale en cas de délabrement. Le dogme est d’être conservateur et le parage doit être minimaliste. La réparation minutieuse nécessite souvent une anesthésie générale, surtout chez les jeunes enfants afin de permettre un affrontement parfait des berges et des lignes cutanéo-muqueuses. Les pertes de substance doivent être traitées par cicatrisation dirigée. Il n’est jamais effectué de lambeaux immédiats chez l’enfant pour les raisons développées plus loin. Vu l’élasticité du squelette facial, les fractures nécessitent un choc violent pour survenir mais la clinique peut être trompeuse. Deux fractures sont souvent peu symptomatiques au niveau des signes faciaux et peuvent être méconnues : la fracture du condyle et sa complication l’ankylose osseuse temporomandibulaire, la fracture du plancher de l’orbite et sa diplopie définitive. Il faut savoir suspecter une maltraitance devant des lésions d’âges différents, et une discordance entre l’histoire racontée et les lésions constatées. Une fois éliminée l’urgence vitale, l’urgence faciale est d’abord à l’œil car les plaies et contusions du globe, souvent sous-évaluées, menacent la vision et relèvent de l’urgence ophtalmologique. L’urgence est ensuite la fracture du plancher de l’orbite sous sa forme dite « en trappe », apanage de l’enfant. La fracture du plancher de l’orbite associée à une immobilité de l’œil et des vomissements incoercibles est la 2 e vraie urgence car elle met en jeu le pronostic de la motricité de l’œil et nécessite une intervention en urgence. Enfin, les traumatismes dentaires de l’enfant ne doivent pas être négligés en raison de leurs conséquences fonctionnelles et esthétiques. La cicatrisation primaire est le plus souvent rapide mais les cicatrices restent longtemps inflammatoires. Le risque hypertrophique existe en cas de contusions et dilacérations associées aux plaies mais aussi pendant la période pubertaire et dans certaines localisations. L’âge interfère sur le résultat car la croissance va soit améliorer soit aggraver le résultat initial, en fonction de la localisation et du mécanisme. Le suivi spécialisé secondaire et prolongé est capital au plan fonctionnel, esthétique et psychologique. Summary Facial traumas are common in children but often unconsidered. Facial injury is responsible of impressive bleeding because of the rich vascularization of the face; this bleeding is often underestimated because of the immediate arterial vasoconstriction that is very strong for children. The blood volume is 80 ml/kg for a newborn, with a total of 250 ml, reaching 70 ml/kg at one year of age. The evaluation must be rigorously performed due to the risk of a sudden decompensation. Regarding the wounds, the primary repair must be performed directly neat or optimal in case of damaged tissues. The rule is to keep maximum of the integrity and to limit debridement. Careful repair often requires general anesthesia, especially in young children, to facilitate a perfect joining of the edges and of the mucocutaneous lines. Losses of substance should be treated by directed cicatrization. Flaps are never performed in children as a first intention for reasons developed below. Given the elasticity of the facial skeleton, fractures require a brutal shock to occur, but the clinical signs can be misleading. For instance, too specific and sometimes ignored, fractures can show weakly symptomatic signs : the fractures of the condylar and the orbital floor, with their respective complication that are temporomandibular bone ankylosis and definitive diplopia. Possible children abuse should be suspected in case of different age lesions and discrepancies between the told story and types of injuries. Once the vital urgency is eliminated, the orbital emergency should be first considered in facial traumas within the ophthalmology specialty because wounds and contusions of the globe are often under-evaluated and threaten the vision. The second emergency is the orbital floor fracture in its ‘trapdoor’ type, specific to the child. Combined with a motionless eye and uncontrollable vomiting, this is the second true urgency because it involves the prognosis of the oculomotricity and requires emergency surgery. Finally, dental trauma should not be overlooked because of their functional and aesthetic consequences. Primary cicatrization is usually rapid but scars remain inflammatory during a long time. The risk of hypertrophy exists in case of contusions and lacerations associated with wounds but also during puberty and in some locations. Age interfere with the result because growth will either improve or worsen the initial result, depending on the location and mechanism. The secondary specialized and prolonged managing and monitoring is capital on the functional, aesthetic and psychological points of view. [ABSTRACT FROM AUTHOR]

Résumé: Les traumatismes balistiques transfixiants de la main posent un problème de prise en charge complexe. Ils nécessitent une couverture dorso-palmaire indispensable à la stabilisation et à la reconstruction des tissus lésés par le projectile mutilant. Nous rapportons un cas original de couverture dorso-palmaire de la main par un lambeau scapulaire/parascapulaire bifolié (LSB) libre. Il s’agit d’un patient de 14ans pris en charge dans notre service dans un contexte de traumatisme balistique des deux mains. La main droite présente un blast avec dislocation du carpe, perte de substance des tendons fléchisseurs et du nerf médian. La vascularisation distale est assurée par l’arcade palmaire profonde perméable depuis l’artère ulnaire. L’artère radiale est interrompue au niveau du premier espace inter-métacarpien. Le parage initial met en évidence une perte de substance cutanée dorsale de 12×7cm et palmaire de 6×3cm. Après stabilisation osseuse et préparation à la reconstruction tendineuse et nerveuse, la couverture est réalisée par un lambeau scapulaire/parascapulaire bifolié libre. Les anastomoses sont réalisées en termino-latérales entre les artères circonflexe scapulaire et radiale et en termino-terminales entre les veines circonflexe scapulaire et radiale superficielle. En l’absence de possibilité de couverture locale, l’utilisation du lambeau scapulaire bifolié libre apparaît comme une technique fiable pour les pertes de substances transfixiantes de la main, nécessitant une stabilisation osseuse et un premier temps de reconstruction tendineuse et nerveuse. [Copyright &y& Elsevier]

Abstract: Objectives: The study objectives were to assess how GPs manage the risk of tetanus in wounds, compared to the French Health Ministry guidelines on tetanus toxoid vaccination and immunoglobulin injections. Design: A cross-sectional survey was made using an online questionnaire sent to 3,165 GPs in the French Rhône-Alpes region. Results: The answer rate was 9.1%. Overall, 64.4% of GP complied to recommendations. The best observance was noted for minor risk wounds and for patients whose last booster vaccination was less than 5years old (P <0.05). Generally, GPs underused tetanus toxoid vaccination (−17.1%) and overused immunoglobulin injections (+37.1%). The main difficulties encountered were assessing the patient and his wound, misuse of immunoglobulin injections, and ignorance of recommendations. Conclusions: The higher the tetanic risk, the less recommendations were observed. A quick diagnostic test and a better availability of new easier to memorize recommendations should help GPs optimize their practices. [Copyright &y& Elsevier]

Long neglected, the pain related to wounds is nowadays recognized as an important issue. This article reviews the physiopathological mechanisms and the types of pain related to wounds, their assessment modalities as well as the pharmacological and non-pharmacological analgesic treatments. [ABSTRACT FROM AUTHOR]

Abstract: The emergence of war during prehistoric times is a recurrent subject that has often been treated in archaeological literature. The present publication, in the light of a synthetic analysis of traces of violent death observed in Neolithic graves in France and completed by new data information obtained from excavations in Germany, in Austria and in Iberian Peninsula, raises the issue of emergence of a real climate of collective violence in the first farmer communities in Europe. From that moment on, violence ascent during Neolithic times can be reported to several factors: factual causes in relation to disputes over territorial boundaries, economic motivations to permit forcible seizure of wealth or valuable objects by incursions, raids and razzias, and to finish social reasons because victorious conflicts are a demonstration of strength of one community against another and they confirm the prestige of the group or the chief. However, the recognized or established examples of violent death and slaughter remain very few in the end within the first farmer and peasant communities in western Europe. They don’t justify the hypothesis of armed disputes on a large scale. We cannot speak of “war”. Actually, this collective violence is the early beginning of real war in this definition, that is to say an aggressiveness organized, managed, socialized and used for the group at the expense of a neighbouring group, referred to other implications. War is established notably by specific armaments adapted to hand-to-hand fight and to collective fight. Moreover, a society dedicated or consecrated to war includes a military caste or a military aristocracy. Once again, the appearance of a warlike elite is not discernable before the beginnings of the Bronze Age. [Copyright &y& Elsevier]

Abstract: Scrotal traumas are rare. Most are blunt traumas caused by a direct blow on the scrotum. The testicle is projected against the pubic arch. Early surgical investigation has considerably improved the prognosis of testicular trauma, and reduced orchidectomy rate. Ultrasonography has also improved the management of scrotal trauma. But there is a controversy about accuracy of ultrasonography in predicting presence or absence of testicular disruption. Ultrasonography should not challenge the dogma regarding systematic surgical investigation of hematocele and enlarged scrotum. Long term outcomes (testicular atrophy, infertility) may be more frequent as previously thought and should be detected. [Copyright &y& Elsevier]

Abstract: In major hand injuries, destroyed joints may be treated by joint transfer, arthroplasty or fusion with or without temporary external fixation. Four immediate digital metacarpophalangeal joint Swanson implants in two patients with amputation or devascularizated near-amputation were reviewed with a 14 years follow-up. No infection was noted. Prostheses were stable with a 31° active range of motion and grip strength was 42% of the opposite side. Functional results were “useful” with patients satisfaction. In one patient, heavy manual worker, implants were replaced fourteen years after trauma because of recent pain on one joint and implants fragmentation. The other patient was painless. Immediate Swanson arthroplasty in major hand injuries may be an alternative in metacarpophalangeal joints destruction. [Copyright &y& Elsevier]

The treatment of wounds is a challenge that caregivers of all specialities encounter daily in the care of an ageing population and chronically ill patients. An interdisciplinary group has been created in recent years within the Hospices-CHUV to assist caregivers in their care of patients with wounds. This group has developed a variety of tools to assist decision-making and offers a range of continuing education for those employees involved in wound care. The authors describe the approach of the group and the documents produced during the first two years of experience. [ABSTRACT FROM AUTHOR]