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Closed degloving injuries are uncommon, high-energy injuries that separate the bony structures from the soft tissue and frequently result in amputation. Because the epidermis is often intact, it is difficult to visualize the extent of the soft tissue damage. Although there is no gold standard of treatment for closed degloving injuries at present, previous cases have reported that neurovascular presentation is a key predictor of amputation Herein, we report a closed degloving injury involving the second through fifth phalanges of the left foot following a crushing injury with a forklift. Despite adequate capillary refill upon initial presentation, the patient ultimately underwent transmetatarsal amputation.

Here we share an interesting case of severe trauma with tissue loss to nearly half of the back and a lacerated perineum in a Covid-19 positive patient in septic shock. This article highlights our experiences and hard lessons learnt in successful management of this complicated injury. Managing severe trauma is a challenge especially with respiratory failure resulting from Covid-19 infection. The patient reported to the hospital during a very difficult period, when proper medical care was difficult as hospitals and wards were filled with Covid positive patients. Managing patients was difficult especially wearing personal protective equipment round the clock. It’s a challenge when an entire team of surgeon, anesthesiologist, nursing staff and paramedics, rose above their daily call of duty to save the patient for her children. It was a fight against time and an many unknown enemy over three months for the entire team. The challenge to save a middle-aged patient from the claws of death against all odds was really miraculous. It was highly rewarding to see the patient going back to the family with a smile.

Penile plication is an important option when considering the surgical management of Peyronie’s disease (PD). In this review, we discuss the evolution and recent advances in the use of penile plication to treat PD. Recent studies have demonstrated the successful application of penile plication to severe PD, which is often managed with more invasive procedures. Penile plication has been successfully combined with excision procedures to address severe forms of PD. In addition, a non-degloving approach was shown to be a safe, non-inferior alternative to degloving in penile plication. New plication techniques have addressed common postoperative complaints such as palpable knots and penile shortening. Updated recommendations to reduce the need for surgical revision were published. Data on long-term patient and partner sexual satisfaction was reported. Finally, the cost-effectiveness of plication was compared to other treatment options. Penile plication remains an important, cost-effective option for the treatment of PD. Recent data shows that penile plication can be used in complex PD cases, and with recent technique refinements, it can be performed with a minimally invasive approach to decrease associated complications.

Introduction Detachment or sharp gross prolonged displacement of the skin, subcutaneous fatty tissue from the underlying fascia over more than 1 % of the body surface with disorders of blood supply to these and sometimes underlying tissues results from high-energy mechanical action of various moving objects and force applied at an angle. Purpose to develop a classification of integumentary tissue detachments based on the variety of clinical types, severity, extent, combination of injuries with a possible quantitative assessment of their severity and extent. Methods Analysis of the literature and our own experience of treating 40 patients with detachments of integumentary tissues enabled to identify criteria for classifying patients into groups. Results A classification and rating scales were developed that reflect the area, depth of tissue damage, localization, general condition of the patient and the stage of the pathological process. Discussion The analysis of the literature on this topic showed that, to date, none of the proposed classifications is optimal. There is no clear definition of the area of compromised integumentary tissues relative to the entire surface of the human body. The issue of pathological process staging has not been reflected; damage and crushing of bones, muscle tissue, neurovascular formations have not been reflected; there is no clearly formulated algorithm for treating a patient depending on the stage and severity of tissue damage. Conclusion Application of the classification of integumentary tissue detachments which has been proposed enables to more objectively assess the nature of local tissue damage, taking into account t he general condition of the patient.

Összefoglaló. Bevezetés: Az orrmelléküreg-daganatok kezelésében a legfrissebb nemzetközi ajánlások alapján továbbra is a sebészi reszekció az elsődlegesen választandó módszer. Bár az endoszkópos technikák fejlődésével a külső feltárással járó műtétek bizonyos esetekben háttérbe szorultak, napjainkban még mindig a Weber–Fergusson-féle metszést tartják a legszélesebb feltárást biztosító technikának, annak ellenére is, hogy a módszer stigmatizáló hegeket és deformitásokat hagy a páciensek arcán. Módszer: A „facial degloving” eljárást mint alternatív, hegmentes technikát először az 1970-es években publikálták, azóta számos módosítását írták le. A szerzők az orrmelléküregi tumorok eltávolítására már 8 éve kizárólag az általuk módosított technikát alkalmazzák. 2012 és 2019 között Klinikánkon 34 beteg esett át a módosított „facial degloving” műtéten. A módszer alapja egy felső szájpitvari behatolásból a középarc területén kialakított oszteoplasztikus lebeny, melynek felemelésével széles rálátás nyílik az orrüregre és melléküregeire, valamint az elülső koponyaalapra is. A műtéti terület a daganat eltávolítását követően jó kozmetikai eredménnyel rekonstruálható. Eredmények: A szerzők akusztikus rinometriai vizsgálatokkal és az arckifejezéseket ábrázoló posztoperatív képi dokumentációval támasztották alá eredményeiket. Az operált oldalon sem az orrbemenet beszűkülését (orrlégzés gátoltsága), sem pedig az arcmozgás zavarait, az arc aszimmetriáját nem észlelték. Betegeik túlélését Kaplan–Meier-görbén ábrázolták. Megbeszélés, következtetés: Habár az eredeti „facial degloving” technikának számos módosítását publikálták, az itt bemutatott módszer (oszteoplasztikus lebeny, melyben a középarc lágy részeinek integritása megtartott) rövidebb hospitalizációs időt és kevesebb komplikációt eredményezett. A bemutatott módosított „facial degloving” technika véleményünk szerint megfelelő és biztonságos sebészi reszekciót biztosít orrmelléküregi rosszindulatú daganatok esetén, továbbá kombinálható endoszkópos technikákkal, és szükség esetén nyitott műtétté alakítható, akár orbitalis kiterjesztéssel. Orv Hetil. 2021; 162(10): 392–398. Summary. Introduction: The widely used external approach (Weber–Fergusson’s incision) for the removal of maxillo-ethmoidal tumors leaves stigmatizing scars and deformities on the patient’s face. As an alternative technique, the scarless facial degloving approach was first described in the 1970’s, and since then, several modifications have been developed. Method: We have been using our modified facial degloving technique for eight years now with maxillo-ethmoidal tumors. Between 2012 and 2019, 34 consecutive patients have been operated with our modified facial degloving approach at the Department of Oto-Rhino-Laryngology and Head-Neck Surgery, University of Szeged, Hungary. We describe our method which provides a wide surgical approach via an osteoplastic flap for the whole nasal and paranasal region, with good cosmetic results. Results and conclusion: We have evaluated our results with acoustic rhinometry and photo-documentation of the facial mimic postoperatively. Neither narrowing of the nasal cavity on the operated side (loss of nasal breathing function), nor facial movement dysfunction was visible in our patients. We represent our patients’ survival in Kaplan–Meier curve. Although several modifications of the original facial degloving approach have been published, in our technique, the novel osteoplastic flap and the intact soft tissue of the nasal and midfacial region results in shorter hospitalization time and fewer complications. Our modified facial degloving technique offers proper and safe surgical resection for tumors of the maxillo-ethmoid region. It can be routinely combined with endoscopic techniques, and, if necessary, can be converted to an open approach. Orv Hetil. 2021; 162(10): 392–398.

Diabetes is a common disease that potentially interferes with healing processes after lower limb trauma. In our presented case a trimalleolar ankle fracture with undiscovered serious soft-tissue injuries resulted in chronic soft-tissue complications in a diabetic patient, requiring three and a half months of hospitalization in a higher level center and the application of state-of-the-art wound treatment, including vacuum-assisted closure therapy, Integra bioengineered skin substitute, split-thickness skin-grafting, and methods enhancing wound healing, such as polarized light therapy and transdermal CO2 delivery. The presented case emphasizes the importance of soft-tissue care and multidisciplinary approach in diabetic trauma patients with poor compliance.

Highlights • A patient underwent open surgical debridement for Type I Morel-Lavallée lesion. • He further developed two recurrences despite percutaneous aspiration. • Sclerotherapy was considered, but established sclerosants were unavailable. • Povidone iodine was used as a sclerosant successfully. • Povidone iodine is an alternative sclerosant for recurrent Morel-Lavallée lesion., Introduction and importance A Morel-Lavallee lesion is a closed degloving injury due to traumatic separation of the hypodermis from underlying fascia. Accumulation of hemolymphatic fluid that occurs is a potential habitat for bacteria. Management options include percutaneous aspiration, open debridement, or a non-surgical approach, each with recurrence risk. In the event of recurrence, sclerotherapy is used. In this case report, after reviewing povidone iodine's efficacy in treating seromas, we used it as a sclerosant for recurrent Morel-Lavallee lesion as the more established options were unavailable in our setting. Case presentation A 49-year-old with no known comorbid presented following a motor traffic accident, with left lateral thigh swelling. He was stable systematically, with a tense, tender left lateral thigh swelling and intact neurovascular assessment distally. X-ray and computed tomography ruled out skeletal and vascular injuries. Magnetic resonance imaging revealed a 580 ml type 1 Morell-Lavallee lesion. Open surgical debridement was done to drain and debride the lesion. He developed two recurrences that necessitated percutaneous aspiration. Doxycycline and talc sclerosants were considered; however, due to their unavailability, povidone iodine was used. It is now five months post-intervention without increased pain, recurrence, or wound complications. Clinical discussion Recurrence is hypothesized to be due to the persistence of fluid loculations, unobliterated dead space, and pseudocyst formation. Sclerotherapy stimulates inflammation that results in fibrosis of the cavity walls causing its obliteration. Doxycycline, the most studied sclerosant in Morel-Lavallée lesion has an efficacy of 95.7%. Conclusion The current report is the first successful use of povidone iodine for sclerotherapy of recurring Morel-Lavallée lesions. Based on povidone iodine experiences as a sclerosant, it is associated with increased analgesic requirements. We cautiously propose its use as an alternative in settings where talc powder and doxycycline powder are unavailable.

Degloving injuries of the fingers represent a reconstructive challenge. Even if poorly described in literature, the proximal ulnar perforator flap (PUPF), based on perforator of the anterior ulnar recurrent artery or directly on a perforator branch of the ulnar artery, meets the requested criteria for the ideal coverage. We performed a cadaveric study in order to clarify the anatomical basis and vascularization of the PUPF flap. Eight injected upper limb specimens were dissected for this study: perforators were followed down to their origin and classified in terms of number, length, diameters and distances between their emergence and specific pre-determined landmarks as the medial humeral epicondyle. At least one ulnar perforator in the proximal third of the forearm was identified in all the specimens. In 50% of the upper limbs, the perforator branch came directly from the ulnar artery, while in the 87.5% a perforator branch came from the anterior recurrent ulnar artery; in 3 out of 8 cases both perforator branches were described. Mean lengths of the perforator branch were 57.9 mm and 44.3 mm, respectively and the mean diameters measured at their origin were 0.99 mm and 1.17 mm respectively. Our data illustrate the consistency of at least one perforator branch from the proximal third of the ulnar artery, most commonly coming from the anterior recurrent ulnar artery. Considering our results, the PUPF could be a good alternative to the classical free flaps for the resurfacing of the finger defects.

Introduction: Morel–Lavallée (MLL) is an uncommon entity that is missed by many physicians, it is the result of a shearing force that leads to degloving of the subcutaneous fat from the underlying deep fascia. Case Report: We present a case of a 15-year-old male patient who presented 3 months after the initial crush injury with a large MLL lesion at the lateral aspect of the right proximal thigh. He was treated with incision and drainage with compressive dressing and a negative pressure drain. Conclusion: Diagnosis of MLL is usually clinical and can be aided with radiological tools like MRI that is the gold standard of imaging in this lesion. Several treatment options are available, ranging from conservative treatment with compressive bandages to percutaneous drainage, injection of sclerotic agents, and surgical treatment with incision, drainage, and debridement. Diagnosis and treatment should be familiar to all caregivers to prevent further complications that could be life or organ-threatening. Keywords: Morel–Lavallée, thigh trauma, chronic Morel–Lavallée, thigh mass.

Abrasions and laceration of face are very common injury in a road traffic accident. Complex Hemi-facial Degloving injury of face is very rare injury in road traffic accident. Reconstruction of face and rehabilitation of patient poses a great challenge to treating surgeon. Here a case of hemifacial Degloving injury of face in A 45-year-old female patient from India is reported.

Exposed or denuded bone is a common complication of wounds of the distal aspect of the limb. This clinical report describes the treatment of an extensive laceration of the right hindlimb of a 12-year-old Hungarian Warmblood Horse gelding, which was managed initially by application of hydrogel dressings to enhance autolytic debridement, subsequently, by cortical fenestration of the denuded cortical bone and by stimulating the production of granulation tissue to cover the exposed bone. An early radiographic sign of sequestrum formation (discrete changes in the outer cortex) was not seen after the injury. Six weeks later, the wound was completely covered with vascularized, healthy-appearing bed of granulation tissue, which was prepared for grafting using the punch technique. A reinforced bandage was applied for the following 7 weeks; the grafts were accepted by granulation tissue. The horse was discharged 20 weeks after admission and the owners were advised to maintain stall rest with hand walking for two weeks. Four years later the owner reported that the wound had completely healed with a good cosmetic outcome and the horse was being used in a carriage.

Background: Tibia plateau fractures constitute 1%of all fractures. Bicondylar fractures account for 10-30%, whereas isolated medial and lateral condyle fractures constitute the remaining injuries. Although only 3% of these fractures are open injuries, many of them have closed degloving, deep abrasions or severe soft tissue injuries which require careful consideration in deciding the timing and the nature of surgery. Proximal tibia fractures may be difficult to treat even in experienced hands due to intraarticular extension, comminution, cartilage damage and soft tissue injuries of the cruciate ligaments and menisci. Aim: To compare the functional and surgical outcomes of operative treatment of unicondylar and bicondylar fractures. Materials and Methods: It was a prospective and comparative study of Surgical and functional outcome of proximal tibial fractures in the department of orthopaedics from July 2019 to December 2019. Clearance was obtained from the hospital ethical committee. Fifty patients were taken into consideration for the study. All patients are selected on the basis of history, clinical examination and radiography. The Schatzker’s classification was used to classify these fractures. The patients were followed up for an average period of 6 to 12 months. The patients were divided into two groups. Twenty-five patients in the unicondylar fracture group 1and 25 patients in the bicondylar fracture group 2. Results: The mean age of group 1 patients was 45.72±10.85 years, and that of group 2 patients was 46.40±8.602 years (p>0.05). In group 1 there were 18 (72%) males and 7 (28%) females, in group 2 there were 21 (84%) males and 4 (16%) females. In group 1, the mean union time was 3.04 ± 0.351 and in group 2 was 3.1± 0.433(p>0.05). In group 1, the mean follow-up time was 12.81 ± 2.09 and in group 2 was 13.04 ± 2.28 (p>0.05). The mean functional score of group 1 was 91.212.27, and in group 2, it was 87±18.2 (p>0.050). In group1 mean WOMAC score was 12.2 ± 21.179, and in group 2 was 16.72 ± 16.923 (p>0.05). 2 patients had hypertension, and none of the patients had diabetes. While in group two, three patients had diabetes, and two patients had hypertension. Conclusion: In the light of the aforementioned results, it was found in the surgical and functional outcomes of both unicondylar and bicondylar fractures of the proximal tibia are satisfactory and comparable to each other. Furthermore, it was identified that Factors such as age, gender and the fracture type did not influence the outcome in both the study groups. Additionally, most fractures occurred in the middle age group with male preponderance in both unicondylar and bicondylar fractures. Keywords: Proximal Tibia Fractures, Unicondyla fractures, Bicondylar Fractures.

Introduction A Morel-Lavallée lesion is a relatively rare, closed, degloving injury. Polytrauma and severe injuries through to seemingly innocuous trauma can distract the clinician from thorough assessment of the affected site. Missed or misdiagnosis of the closed lesion is reported from both a clinical and imaging perspective. Case report A 46-year-old male is discharged from accident and emergency with a shoulder injury following a cycling accident. Ten days post trauma, an advanced practice physiotherapist suspects a lateral thigh Morel-Lavallée lesion during a telephone assessment (Covid-19 restrictions). A face to face appointment with imaging the following day confirmed the suspicion. Discussion The aetiology, imaging and clinical management of a Morel-Lavallée lesion is discussed. The addition of diagnostic ultrasound skills to clinical assessment in this case report may have improved patient care and experience by offering a ‘one stop shop’ to care. Formal training in musculoskeletal ultrasound imaging is emphasised. Conclusion Thorough history taking, clinical reasoning and subsequent application of robust imaging led to the identification of a Morel-Lavellée lesion and, in this case, highlights the value of a point of care ultrasound model in a triage setting.

Factor V Leiden mutation is a rare anomaly, which is prone to increase the thrombotic incidents in those who have the abnormality compared to the normal population. Herein, we report a patient with Factor V Leiden mutation, which was detected post-operatively during evaluation of ecchymosis and ischemia on the glans penis and penile skin following skin degloving and circumcision. Luckily, glans ischemia responded hyperbaric oxygen treatment and intravenous pentoxyphylline therapy. Factor V Leiden mutation is a “Hidden Danger,” which the surgeons should keep in mind in cases of post-operative venous thrombosis leading to ecchymosis and superficial or deep tissue loss.

To describe the largest case series of lower extremity traumatic internal degloving injury, i.e. Morel-Lavallée lesion (MLL) in the pediatric and adolescent population, its treatment and outcomes.Retrospective review of patients under 18 years who presented with MLL to a tertiary children's hospital. Demographic, clinical, radiographic, treatment and outcomes data were collected. Descriptive statistical analysis was conducted.38 patients having MLL with mean age 14.6 years were classified into two groups: hip/thigh MLL (nine patients) and lower leg MLL (29). Most common cause of lower leg and hip/thigh MLL was sports injury (79.3%) and motor vehicle accident (MVA) (33%) respectively. Most implicated sports were football and baseball. Primary care physicians/pediatricians were the initial treating providers for 63% of patients. Imaging modality of choice was magnetic resonance imaging (MRI) for lower leg MLLs (72.4%) and ultrasonography (US) for hip/thigh MLL (66.7%). Twenty-five (65.8%) patients were treated with conservative management, 12 (31.6%) with minimally invasive methods and 1 (2.6%) needed surgical management. Average return to normal activities took 14.3 and 9.1 weeks for hip/thigh and lower leg MLL, respectively. Twenty-four patients with adequate documentation demonstrated lower extremity functional score (LEFS) and pain level of 74/80 (92.5%) and 0.7/10, respectively, at mean 12.5 months follow-up.In contrast to adult injury literature, pediatric MLLs are more common in the leg/knee than hip/thigh region and caused mostly by sports injuries. Primary care physicians are the initial treating providers for the majority of the patients. Intervention is more often needed in the hip/thigh MLLs as opposed to non-operative management for lower leg injuries. This large case series on MLL in the pediatric population demonstrates differences in the management of hip and thigh lesions when compared to the management of the knee and leg lesions in the majority of these patients. Non-operative management in the majority of these lesions provided overall satisfactory outcomes.

Purpose Congenital penile curvature (CPC) is a rare condition with surgical correction being the standard therapy. In the current study, we report long-term results analyzing the surgical and functional outcomes using a modified Nesbit technique. Materials and methods Patients with CPC were included. After penile degloving and mobilization of the neurovascular bundle an artificial erection was performed. An ellipsoid part of the tunica albuginea was excised at the point of maximum curvature on the convex side of deviation. The tunical defect was then closed by interrupted absorbable sutures with inverted knots. Results of correction were documented intra- and postoperatively by artificial erection. Pre- and postoperative evaluation included measurement of penile length and curvature after pharmacological erection. Erectile function, alteration in glans sensation, palpable suture as well as short- and long-term complication were also recorded using validated questionnaires and objective examinations. Results Fifty-five patients with mean age 26.93 years (14-66 years) and mean curvature 69.81° (25°-90°) were included in the study. Ventral or ventrolateral curvature was observed in 83.6%. Mean operative time was 106.8 minutes (55-169 minutes). Totally straightness of the penis was achieved in 51/55 patients (92.8%). After a mean long-term follow-up of 36.68 months (4-87 months), erectile function worsened in 3.6% of patients. Median penile length loss associated with this technique was 1.7 cm (0-3.0 cm). Conclusions Surgical therapy of CPC using our modified Nesbit technique is feasible, safe and provides reliable long-term outcomes, representing an alternative for surgical correction of CPC.

Severe complications and morbidity after orthognathic surgery are infrequently encountered and even more infrequently reported considering the extent to which this procedure is performed by surgeons within the specialty of maxillofacial surgery. Avascular necrosis of the maxilla after Le Fort I osteotomy is perhaps the most dreaded outcome of orthognathic surgery. However, it accounts for an extremely small subset of overall surgical complications. The reported risk factors associated with avascular maxillary necrosis include segmental osteotomies, vertical posterior impactions, large transverse expansions, anterior advancements exceeding 9 to 10 mm, an improper surgical technique, excessive soft tissue degloving of the maxilla, intraoperative hemorrhage, perforation or laceration of the palatal soft tissue pedicle, previous maxillary or palatal surgery, and other medical comorbidities. Although anecdotal cases of total maxillary necrosis after orthognathic surgery have been alluded to within the specialty as a whole, to the best of our knowledge, no previous studies have reported total maxillary necrosis occurring after routine orthognathic surgery. We have presented a truly unique case of total maxillary avascular necrosis that occurred after standard 1-piece Le Fort I osteotomy in a patient without medical or surgical risk factors for the complication either known preoperatively or identified postoperatively. The resultant maxillary defect from total avascular necrosis was comprehensively treated with surgical debridement of the nonviable maxilla, osteocutaneous fibular free flap reconstruction, staged endosseous implant reconstruction of the neomaxilla, and comprehensive prosthodontic rehabilitation.

A 12-year-old girl presented to the Department of Paediatric Dentistry of the Toulouse University Hospital 10 days after a facial injury, complaining of persistent pain and halitosis. Previous examinations only reported trauma of the upper incisors. Further clinical exploration showed an 8 cm laceration of the oral mucosa in the lower labial sulcus, 1.5 cm inferior to the gingival margin and exposing the symphyseal bone. The diagnosis of mental protuberance degloving was established. The treatment consisted of debridement of the wound, removal of the necrotic tissue, multiple plane sutures and antibiotics. Complete healing of the wound with no sensory deficit was achieved. Mental degloving injuries occur when a shearing force is applied to the soft tissues overlying the chin, stripping them from the labial bone. This type of wound is rare and can go undetected if a meticulous oral examination is not performed. Early management is essential so healing is not compromised.

Background For volar soft tissue defects of the proximal interphalangeal (PIP) joint, free flaps are technically challenging, but have more esthetic and functional advantages than local or distant flaps. In this study, we compared the long-term surgical outcomes of arterial (hypothenar, thenar, or second toe plantar) and venous free flaps for volar defects of the PIP joint.Methods This was a single-center retrospective review of free flap coverage of volar defects between the distal interphalangeal and metacarpophalangeal joint from July 2010 to August 2019. Patients with severe crush injuries (degloving, tendon or bone defects, or comminuted/intra-articular fractures), thumb injuries, multiple-joint and finger injuries, dorsal soft tissue defects, and defects >6 cm in length were excluded from the study, as were those lost to follow-up within 6 months. Thirteen patients received arterial (hypothenar, thenar, or second toe plantar) free flaps and 12 received venous free flaps. Patients’ age, follow-up period, PIP joint active range of motion (ROM), extension lag, grip-strength ratio of the injured to the uninjured hand, and Quick Disabilities of Arm, Shoulder & Hand (QuickDASH) score were compared between the groups.Results Arterial free flaps showed significantly higher PIP joint active ROM (P=0.043) and lower extension lag (P=0.035) than venous free flaps. The differences in flexion, grip strength, and QuickDASH scores were not statistically significant.Conclusions The surgical outcomes of arterial free flaps were superior to those of venous free flaps for volar defects of the PIP joint.

Here, we present a 45-year-old male patient who had right leg fracture in several pieces, arterial ischemia, multiple muscle, tendon losses and degloving injury on the distal thigh and knee undergoing emergency surgery due to a high-energy traffic accident and explain our experience with reconstruction of below knee stump using free plantar fillet flap in order to prevent above knee amputation in a patient with vascular injuries, multi-part fractures and soft tissue losses in the lower extremity.

As the literature has tended to focus on injuries and deaths due to active dog attacks, the following review was undertaken to examine the range of circumstances and mechanisms that may be associated with all types of fatal encounters with dogs. A search was undertaken of the literature and the Forensic Science SA, Australia, autopsy database for cases where deaths had been caused by dog-related activity. Only 2 cases were found in the autopsy database over a 15-year period from 2005 to 2019. The first was a 55-year-old man who bled to death from a large degloving dog bite to his forehead exacerbating underlying cardiovascular disease. The second was a 40-year-old previously splenectomized man who died of Capnocytophaga canimorsus sepsis shortly after being bitten by his dog. Dogs may be involved in vehicle crashes if drivers swerve to avoid them or if pedestrians attempt to rescue dogs that have strayed onto roads. In the literature, trauma has also occurred from "non-bite dog-related injuries" where individuals have been pulled over by, or tripped on, dogs. Dogs may also be responsible for specific types of infections such as echinococcosis and C. canimorsus, which may have potentially lethal consequences. Thus, the types of cases of injuries, illnesses, and deaths associated with dogs encountered by pathologists in a forensic context may be extremely diverse and not always straightforward.

Morel Lavallee lesion or closed degloving injury is normally associated with severe trauma and occurs when the skin and subcutaneous fatty tissue traumatically and abruptly separated from the underlying fascia thus creating a potential space filled with fluid. MVA is the commonest etiology but large or lethal Morel Lavallee is extremely rare. A 35 years old, female pillion rider was involved in a motor vehicle accident and sustained injuries to the left pelvis and thigh. Emergency laparotomy and intra-op abdominal and bilateral lower limb arteriogram revealed no significant finding. Her general condition and vital signs continued to deteriorate despite aggressive resuscitation and eventually died. Post-Mortem Computed Tomography and Post-Mortem Computed Tomography Angiogram was performed and revealed a large cavity in the left thigh suggestive of a lethal Morel Lavallee lesion. Findings were confirmed by conventional autopsy.

Postoperative seroma is a common complication of many surgical procedures in which anatomical dead space has been created. A particular case of lesion in which seroma occurs is the Morel-Lavallée lesion (MLL), which is an uncommon closed soft-tissue degloving injury that develops after high-energy trauma or crush injury where shearing forces separate the subcutaneous tissue from the underlying fascia. The diagnostic evaluation begins with an adequate history and physical examination, followed by instrumental research with ultrasonography, computed tomography, and magnetic resonance imaging. Postoperative seromas and MLLs share a similar pathology and natural evolution as both injuries, once chronic, develop a pseudobursa; thus, the authors think that the same treatment algorithm may be suitable for both the lesions. Several strategies for the treatment of post-surgical and post-traumatic seromas have been described in the literature, ranging from conservative measures for acute and small injuries to surgical management and sclerotherapy for chronic and large ones. Despite some seromas resolving with conventional management, lesion recurrence is a matter of concern. The authors present their experience in the treatment of both post-surgical and post-traumatic chronic seromas not responsive to conservative treatments by surgical drainage of the seroma, capsulectomy, and application of vacuum-assisted closure therapy to allow granulation tissue formation, dead spaces obliteration, and wound healing. Primary wound closure with closed suction drain placement and an elastic compression bandaging are finally performed. From 2014 to 2019, a total of 15 patients (9 females and 6 males) were treated for recurrent chronic seromas with the proposed surgical approach. Five cases were MLLs, while 10 cases were postoperative seromas. The patients were between 33 and 79 years old, and they were followed up at 4 weeks and 3 and 6 months after surgery. All 15 patients with chronic seromas not responsive to conservative treatment showed a complete resolution of the lesions with the proposed treatment approach with no evidence of lesion recurrence, proving its effectiveness.

We examined the management and outcome of patients suffering complex paediatric lower limb injuries with bone and soft tissue loss.Patients were identified from our prospective trauma database (2013-2018). Inclusion criteria were age (18 years) and open lower-limb trauma. We assessed severity of soft tissue and/or bone loss, fracture complexity, surgical techniques and time to surgery. Paediatric quality of life and psychological trauma impact scores (HRQOL and CRIES), Ganga Hospital Injury Severity score (GHISS), union and complication rates were measured.We identified 32 patients aged between 4 and 17 years. Twenty-nine patients had open tibia fractures including 14 patients with bone loss, one patient had an open femur fracture, one patient an open talus fracture and one an open ankle fracture with dorsal degloving. Thirty injuries were classified intra-operatively as Gustilo IIIB (or equivalent) and two injuries as Gustilo IIIC. In 10 patients primary skin closure was achieved by acute shortening following segmental bone loss. Twenty-two patients required soft tissue coverage: 17 free vascularised flaps, two fascio-cutaneous flaps and three split skin grafts were used. Two patients required vascular repair. Soft tissue coverage was achieved within 72 hours in 26 patients (81%) and within a week in 30 patients (94%). The surgical techniques applied were: circular fine wire frame (19), monolateral external fixator (4) and open reduction internal fixation (8). Median follow up time was 18 (7-65) months. Paediatric quality of life scores were available in 30 patients (91%) with a median total score of 77.2 out of 100. The psychological trauma impact scores showed one in three patients was at risk of developing post-traumatic stress symptoms (PTSD). The GHISS scores ranged from 6-13. All fractures went on to unite over a median time of 3.8 (2-10) months. Three patients (9%) had major complications; two flap failures requiring revision, one femur non-union requiring revision fixation.Limb salvage and timely fracture union is possible in children with complex lower limb trauma. Early intervention providing adequate debridement, skeletal stabilisation and early soft-tissue cover including the option of free microvascular reconstruction in small children when required, delivers acceptable outcomes. A multidisciplinary team approach including clinical psychologists to address the psychological impact of trauma provides optimal holistic care for these children and adolescents. Therefore, treatment for these patients should only be performed in paediatric major trauma centres.

Morel-Lavallee lesion has been described as a post-traumatic soft tissue degloving injury. It is commonly seen in association with road traffic accidents or sports injuries where there is separation of the hypodermis layer from the deeper fascia caused by a shearing force. These injuries occur around the mid-torso, specifically at the flank, lumbar spine, scapula, buttocks and the knee but are most commonly seen over the greater trochanter. There is a complex serosanguinous fluid collection containing blood, lymph and necrotic material within the separated tissue planes. Various treatment modalities like compression bandaging, sclerodesis, percutaneous aspiration, open debridement, quilting sutures and VAC (vacuum assisted closure) therapy have all been described in literature, however a clear consensus on the management protocol does not exist. Herein we reported a 45 year old gentleman who presented with a persistent fluctuant swelling over his left thigh following a motor vehicle accident. He had a history of multiple aspirations of the collection. Upon presenting to our Institute he underwent incision and drainage with sclerotherapy followed by open drainage and debridement with low suction drains. However on follow up visits there was recurrent swelling over the inferior most dependent aspect of the lesion which was finally managed by VAC therapy. The patient eventually returned to normal activity after 4 months from the initial injury with no residual loss of function. The clinical significance of this case is to emphasize that a high degree of suspicion and early use of imaging modalities like MRI in suspected patients are essential to provide timely and appropriate treatment. We also aim to discuss the efficacy of various forms of treatment as per the available literature which shows that a low threshold for operative management is associated with lower recurrence and complication rates.

Morel-Lavallee lesion is a rare post traumatic soft tissue injury. It results in separation of the skin and subcutaneous tissue from the underlying fascia. An underlying blood filled cystic cavity is created. It is commonly causedby a shearing force resulting in separation of the hypodermis from the deeper fascia. It is most commonly seen around the greater trochanter. These injuries also occur at the flanks, buttocks, lumbar spine, scapula and the knee. Separation of the tissue planes result in a complex serosanguinous fluid collection with areas of fat within it. These lesions are usually missed during initial examination and become evident after few weeks or months. They may be associated with fractures. Magnetic resonance imaging is the modality of choice for the evaluation of this lesion. It plays a significant role in its diagnosis. Keywords: Morel-Lavallee lesion; post traumatc injury; hidden injury

A 3-year-old boy presented after a hyena bite to the skull in Tanzania. A large degloving wound with herniating cerebrum was seen in the right parietotemporal region. A CT scan confirmed a large 8-cm skull defect. The patient was taken for irrigation and debridement, but due to significant tissue loss, the skin could not be closed. CSF leaked from the wound, and two additional operations for attempted closure were undertaken but failed. The plastic surgery team was consulted, but no closure was done because of the procedure’s complexity, lack of resources, and cost. CSF diversion could not be performed due to no available lumbar catheter or external ventricular drain. Meningitis developed, leading to severe hyponatremia and death. The current case highlights both the unique mechanism of a hyena bite requiring neurosurgical intervention and the realities of practicing neurosurgery in a low-resource setting.

OBJECTIVE: This study looks at the outcome of percutaneous quilting technique for the treatment of closed degloving injuries or Morel-Lavallée lesions (MLL). DESIGN: Prospective single-centre nonrandomized case series. PARTICIPANTS: Patients with MLL visiting our hospital between January 2012 and May 2018. METHOD: The method involves percutaneous single-stage suturing of skin and deep fascia with heavy, non-absorbable, non-braided sutures starting from periphery to centre. OUTCOME MEASURES: Resolution of the lesion. RESULTS: Twenty-two patients with MLL treated, which included 18 males and 4 females with an average age of 22 (range 16–52). Lesions varied in length from 12 to 60 cm. The average time gap from the injury to drainage of the lesion was 7 days (range 2–60 days). We followed these cases weekly for 4 weeks and then once a month until 6 months and then at the end of the year. All 22 cases healed uneventfully. CONCLUSION: Percutaneous drainage along with suturing of the skin and subcutaneous tissue to deep fascia prevents the discordant movement and obliterates the dead space-aiding apposition of the layers. This is a simple and effective procedure with low recurrence rates that addresses the primary pathology of MLL. LEVEL OF EVIDENCE: Therapeutic level IV.

Objective To improve cosmetic and functional results of buried penis correction in boys using a modified universal surgical approach – Midline Incision Rotation Flaps. Materials and Methods We retrospectively analyzed results of 18 patients who underwent buried penis surgical treatment according to the Midline Incision Rotational Flaps technique from 2013 to 2016. The results were assessed by the surgeon 1, 3, 6 months after surgery, then yearly. Parents filled out postoperative survey after 1 month. The surgery commences with a midline longitudinal skin incision on the ventral surface. Following, a circumferential incision along the coronal edge allows to perform full degloving. Excessive subcutaneous fat tissues are removed from the peno-pubic area. Next stage is the formation of the peno-scrotal and peno-pubic angles by fixation of the skin at the base of the penis. Then, the edges of the skin flaps are opened, forming Byar's flaps. The skin defect along the ventral surface is covered with rotated triangular skin flaps with nourishing vessels. Uneven excessive skin is dissected and interrupted skin sutures are placed. Results and Discussion The median age of patients was 1.4 years with a median follow-up of 56 months (range 36-72). 16 patients (89%) obtained good results, and 2 patients (11%) - satisfactory. The results showed that size and appearance are close to natural and satisfying to parents of the patients. Conclusion The suggested method of buried penis repair using Midline Incision Rotation Flaps technique allows to obtain the most satisfactory both cosmetic and functional results with minimal complication risk.

To critically evaluate inner preputial graft (IPG) used in staged proximal hypospadias with severe chordee regarding cosmetic and functional outcomes. In this prospective study, patients with primary proximal hypospadias with moderate to severe chordee (> 30°) after penile degloving were considered candidates for staged repair between June 2011 to July 2017. After transection of the urethral plate (UP) and penile straightening, the bare shaft was covered with IPG. Tubularization of the graft was done as a second stage. Cosmetic and functional outcomes were assessed using HOSE score and uroflowmetry (UF). Additionally, factors influencing success were analyzed. In all, 38 consecutive cases were included. Native meatus was at proximal penile in 17, penoscrotal in 11, scrotal in 7, and perineal in 3 cases. Median age was 26 and 32 months at the first stage and the second stage, respectively. Preoperative testosterone was given for ten patients with a small penis and/or severe curvature. The mean follow-up was 18 ± 8.2, median 15 months. Grafts took well in all cases after the first stage except one. Cosmetic success achieved in 33 (86.8%). A total of ten complications occurred in six cases. Unplanned intervention was needed in 5/38 cases. Functionally, UF study revealed normal flow in 7/23 (30.4%), equivocal in 11/23(47.8%), and obstructed flow in 5/23(21.7%). Inner preputial graft use in proximal hypospadias with moderate to severe chordee seems to have a good technical outcome and functionally mimic the normal urethral function and could be considered an ideal option for substitution urethroplasty.

Complex lower limb trauma is a common and major challenge. Limited lower limb local flap options especially in the distal third often necessitate free flap surgery. Fasciocutaneous perforator flaps are an exciting option presenting with less overall morbidity, requiring less specialised expertise than free flaps and can provide excellent cover for small to moderate size defects. To assess the outcomes of fasciocutaneous perforator flaps at our hospital over a 3-year period. Retrospective analysis of all fasciocutaneous perforator flaps performed over that period. There were 20 patients with an average age of 29.8 years (range 10–80). Fifteen were males and five were females. Four were children. Pedestrian vehicle accidents (n = 10), motor vehicle accidents (n = 4), cyclist accident (n = 1), gunshot (n = 1), falls (n = 3) and blunt trauma (n = 1) resulted in Gustillo 3B lower limb fractures (n = 13), full thickness degloving wounds (n = 5) and crush injuries (n = 4). Location of the defects includes the distal third (n = 9), middle third (n = 6), combination middle-distal third (n = 4) and proximal third (n = 1). Average procedure was 129 min (range 70–180) and average time to surgery was 4.3 days (range 0–11). All flaps survived at a mean follow-up of 7 months (range 1–12 months). Complications included epidermolysis (n = 2), partial necrosis requiring limited debridement and split skin graft (n = 3), partial necrosis that healed through secondary intention (n = 1) and tip necrosis (n = 2). No donor site complications were experienced. There were no skin graft losses. Evidence for fasciocutaneous perforator flaps in the lower limb is abundant. This study further substantiates the literature since free style perforator flaps can also be successfully employed in complex traumatic lower limb defects. They appear to be reliable when based on the posterior tibial artery system of perforators for middle and/or distal defects. They are associated with reduced operative time, preservation of the source artery and underlying muscle function, superior aesthetics and fewer complications when compared to free flaps. It has evolved into our first choice for small to moderate size complex defects of the lower limb. Level IV, risk/prognostic study.

We report a case of 22 years old male patient who is a worker in a factory and sustained degloving injury of his left thumb in a machine while working. There was loss of the pulp of the thumb extending circumferentially to the dorsal aspect with loss of the skin of the terminal phalanx and part of the proximal phalanx. The nail and germinal matrix were lost with exposure of the bone and extensor pollicis longus tendon insertion. The thumb was totally covered with a combination of two flaps: Moberg flap with V-Y advancement was used to cover most of the volar surface of the thumb and reverse adipofascial cross finger flap from the adjacent index finger was used to cover the dorsal surface and the tip of the thumb. The reverse adipofascial cross finger flap was covered with split thickness skin graft. Three weeks later this flap was divided and the thumb was mobilized freely. The patient had a full range of movement of the thumb and index finger with few settings of physiotherapy postoperatively. We recommend combining both of these flaps to reconstruct degloving injury of the thumb as they provide near adjacent tissue of similar texture, preserve sensation at the volar aspect of the thumb and also avoid the complications of the distant flaps.

Introduction: Penile fracture is a rare urological emergency, best managed by early surgical intervention, but the data on subsequent sexual function is sparse. This study was designed to analyze the clinical spectrum and sexual function after penile fracture repair at our tertiary care center. Materials and Methods: Ambispective observational study was undertaken from July 2002 to August 2019 which included patients admitted with a history of trauma to the penis in the erect state. The clinical presentation, etiology and the details of the surgical management were noted. Patients were contacted telephonically and were called for follow-up. They were evaluated for the presence of penile nodules or curvature, and the erectile function was objectively recorded using the Sexual Health Inventory for Men (SHIM) questionnaire and the Erection Hardness Score (EHS). Results: Median age at injury was 37 years, and injury during the sexual intercourse (33/43) was the most common etiology. Five patients presented with blood at the meatus. Ultrasound was performed in 27 patients and could detect the injury with a 55% sensitivity. All but one case were repaired through a subcoronal degloving incision. At a median follow-up of 36 months, follow-up data of 20 patients were available. Of the 20 patients, 14 were sexually active. The mean SHIM score was 21.36 ± 1.33 and the mean EHS was 3.21 ± 0.43. Four of the 20 patients developed penile nodule while 2 of them had penile curvature which was not bothersome. Conclusion: Penile fracture remains primarily a clinical diagnosis. Although prompt diagnosis and an emergent surgical exploration provides good outcomes in terms of preservation of erectile function, patients should be apprised about the problems of penile nodule and curvature.

Highlights • Morel Lavallée Lesion is an elusive diagnosis & can cause a life-threatening state. • Diagnosis of Morel Lavallée Lesion is clinical, but aided by several modalities. • There are several treatment options for Morel Lavallée Lesion. • Morel Lavallée Lesion should be treated when diagnosed., Introduction Morel-Lavallée lesion (MLL) is an uncommon entity, by which shearing forces result in a closed degloving lesion. This can result in an infected hematoma and lead to a life-threatening situation. Presentation of case We present a case of a 59-year-old patient who presented to our emergency department. This patient had a crushing injury, and later was found to have an infected MLL. The patient was treated with surgical drainage, and 2 split thickness skin grafts. The patient fully healed. Discussion We review the current literature regarding MLL and diagnostic tools in order to accurately and rapidly diagnose this often-missed entity. Special emphasis is given to the treatment of MLL, with the current knowledge as reflected in the literature. Conclusions It is important for caregivers to know the diagnostic steps and pitfalls of this elusive diagnosis in order to diagnose and treat MLL quickly, before it turns into a life-threatening state for the patient.

Gross maxillofacial injuries are challenging to manage because they can be complicated by airway obstruction, injuries to the cervical spine, and cranial structures. Deformities from such injuries have lasting psychological effects which if not addressed can be devastating. We present a 21-year-old male motorcyclist who was involved in a motor traffic collision and sustained avulsion and degloving of the forehead skin, left eyebrow, left upper and lower eyelids, the nose, the left cheek and part of the right cheek, upper and lower lips, and the skin overlying the chin. His airway was compromised; hence rapid sequence intubation was done to secure it. Thereafter single-stage primary reconstruction and repair were done. A multidisciplinary team approach involving different specialties yielded good outcomes for this patient's condition.

This is a case of a proximal corpus cavernosa fracture presenting with scrotal edema and butterfly perineal ecchymosis sparing the penile shaft. Preoperative MRI obviated the need for circumferential incision and degloving of the penis and guided immediate incision over the area of corporal injury. The presentation, diagnostic work-up, and surgical treatment are discussed.

Objective. The aim of our article is to highlight the im­portance of the immediate treatment of lower extrem­ity degloving injuries, in order to prevent complica­tions. Cases Presentation. Here we present two cases of degloving injury of the lower extremity, both result­ing from motorway accidents. The first one concerned a 65-year-old man suffering from multiple limb frac­tures and a degloving injury of the right thigh, which was immediately treated with extensive debridement and primary full-thickness skin graft re-approxima­tion. The second case involved a 63-year-old woman who presented with cervical vertebrae fractures and a degloving injury of the left posterior leg, which, due to the severity of her condition, was treated with a delayed approach resulting in skin necrosis, which required surgical debridement, alginate dressing and foam cover. Conclusions. The optimal approach to treatment of degloving injuries is challenging and they warrant immediate surgical attention. An early diag­nosis and the evaluation of tissue viability are impor­tant in order to prevent limb-threatening situations.

Introduction Previously, incisionless plication (IP) for correction of congenital penile curvature (CPC) has been performed after penile degloving via a circumscribing incision. Aim To describe our experience with non-degloving incisionless penile plication (NDIP) for correction of CPC and compare these outcomes with those of men who underwent degloving incisionless penile plication (DIP). Methods We conducted a retrospective review of men ≤ 45 years of age who underwent incisionless penile plication for correction of CPC between 2008 and 2020 at two adult tertiary hospitals. Patients underwent either NDIP, performed through a 2-3 cm longitudinal incision along the proximal-to-mid shaft opposite the point of maximum penile curvature, or DIP via a sub-coronal circumscribing incision. Main Outcome Measures Surgical and patient-reported outcomes were compared between the non-degloving and degloving groups. Results Among the 38 men (mean age, 26 years) who met the inclusion criteria, 25 underwent NDIP, including 6 patients with biplanar curvature (2 Ventral, 4 Dorsal, 6 Lateral). Thirteen patients underwent DIP, including 1 patient with biplanar curvature (1 ventral, 1 lateral). Curvature reduction was 50 ± 23 degrees for the NDIP group and 36 ± 10 degrees for the DIP group (P = .04). Five (20%) patients in the NDIP group and nine (69%) patients in the DIP group experienced a reduction in stretched penile length following plication (SPL) (P = .01). One patient in the NDIP group underwent an additional plication for recurrent curvature. Conclusion Both NDIP and DIP are safe and highly efficacious techniques for the correction of CPC.

To report a case of pediatric penoscrotal injury and review of the literature for similar cases to evaluate the prevalence, etiology of injuries, methods of reconstruction, surgical complications and end result