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CASE REPORT
Year : 2020  |  Volume : 53  |  Issue : 4  |  Page : 156-158

“Drill holes” made on exposed scalp bone promotes secondary intention healing of extended scalp laceration wounds: A Mbabane Government Hospital approach in the Kingdom of Eswatini


1 Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan
2 Department of Surgery, Taiwan Medical Mission in Eswatini, Taipei, Taiwan

Date of Submission27-Nov-2019
Date of Decision25-Mar-2020
Date of Acceptance13-May-2020
Date of Web Publication20-Aug-2020

Correspondence Address:
Chi-Cheng Tu
P. O. Box 3160, Mbabane, H100, Kingdom of Swaziland.

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_103_19

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  Abstract 


Granulation tissue growth over exposed bone may be facilitated by creating fenestrations on the exposed bone. We report the case of a 6-year-old girl with a large-sized scalp laceration (10 cm × 6 cm) with bone exposure (4 cm × 3 cm) due to a road traffic accident in the Kingdom of Eswatini. We treated the wound with saline-soaked gauze dressing and drilled several holes on the exposed bone to enhance secondary healing. The aim of this case report was to provide a successful application of “Drill holes” procedure or trephination of exposed calvarium for the treatment of exposed bone and large-sized scalp lacerations in resource-poor areas, where flaps or more complicated procedures are not feasible.

Keywords: Delayed wound healing, extended scalp laceration wounds, granulation growth, trephination


How to cite this article:
Chou PH, Tu CC. “Drill holes” made on exposed scalp bone promotes secondary intention healing of extended scalp laceration wounds: A Mbabane Government Hospital approach in the Kingdom of Eswatini. Formos J Surg 2020;53:156-8

How to cite this URL:
Chou PH, Tu CC. “Drill holes” made on exposed scalp bone promotes secondary intention healing of extended scalp laceration wounds: A Mbabane Government Hospital approach in the Kingdom of Eswatini. Formos J Surg [serial online] 2020 [cited 2020 Sep 25];53:156-8. Available from: http://www.e-fjs.org/text.asp?2020/53/4/156/292722




  Introduction Top


In the Kingdom of Eswatini, head injuries are becoming more frequent in children due to the substandard road safety laws. The common mechanisms of head injury include falls, road traffic accidents, assaults, and even child abuse. Furthermore, head injuries always cause scalp laceration simultaneously. However, there is no proper equipment and plastic surgeons struggle to perform microsurgical flap repair of large-sized and complicated scalp lacerations in the Mbabane Government Hospital. Therefore, the wounds will be left to heal by secondary intention.

We report the case of a 6-year-old girl with a large-sized scalp laceration (10 cm × 6 cm) with bone exposure (4 cm × 3 cm) due to a road traffic accident. We treated the wound with saline-soaked gauze dressing and drilled several holes on the exposed bone to enhance secondary healing. Trephination of the outer table encourages granulation of tissue, and keeping the wound moist encourages granulation to which wound contracture can occur over a wound bed.

A 6-year-old girl was sent to our emergency department after a road traffic accident on February 18, 2019. According to her mother's statement, she was thrown from the pickup truck and injured her head. It resulted in a scalp laceration over her frontal area. Her vital signs were stable with mild restlessness found on arrival, and her Glasgow Coma Scale showed E4V5M6. Skull X-ray and brain computed tomography were arranged, and the result revealed no obvious skull fracture or intracranial hemorrhage. Intact muscle power over four limbs was also noted. After the initial proper wound management and hemostasis, she was then admitted to the pediatric ward for further evaluation and observation. The inspection showed a large-sized scalp laceration (10 cm × 6 cm) with exposed bone (4 cm × 3 cm) on her frontal area [Figure 1]. Therefore, the wound care with local debridement and saline-soaked gauze dressing was performed every 2 days. Antibiotics were also administered for infection control. However, healing of the exposed scalp bone area was delayed after 1 month [Figure 2]. On March 21, we used a medical electric drill to drill several holes with radii of 3–4 mm and at depths of 2–3 mm on the exposed bone in several areas under general anesthesia in the operating room [Figure 3]. Then, we kept wound care with saline-soaked gauze dressing every 2 days under strict aseptic conditions. One and half month after the “drill holes” procedure, de novo granulation tissue emerged throughout the original exposed skull [Figure 4]. Wound healing has occurred, and we performed a local flap to close the wound with Nylon sutures on April 30, 2019 [Figure 5]. The postoperative period was uneventful, and the patient was discharged on May 6. After removing the stitches, mild wound dehiscence was noted during outpatient clinic follow-up [Figure 6]. Under the proper wound care and medical treatment, wound healing was much improved [Figure 7].
Figure 1: A large-sized scalp laceration (10 cm × 6 cm) with exposed bone (4 cm × 3 cm) at the patient's frontal area

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Figure 2: The area of exposed scalp bone remained delayed healing after 1 month

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Figure 3: Intraoperative photograph showing “drill-made holes” (arrow) that were performed through the exposed bone

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Figure 4: Photograph showing the granulation tissue emerged through the original exposed skull at different times. (a) Fifteen days after the procedure. (b) Twenty-five days after the procedure. (c) Forty days after the procedure showing the granulation tissue covering the exposed frontal region completely

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Figure 5: Wound closure with local flap and nylon sutures

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Figure 6: Wound condition (3 months after the procedure)

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Figure 7: Wound condition (4 months after the procedure)

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  Discussion Top


When dealing with large-sized scalp lacerations, the initial clinical assessment should provide rapid identification of potentially fatal conditions. Afterward, the clinical evaluation should identify associated serious head injury, laceration of the galea aponeurosis, and bony defect of the skull as well. Smaller wounds (<2 cm) with a vascularized bed may heal over the course of a few weeks, whereas larger wounds may take several months to completely close.[1] Bone may be exposed in a full-thickness scalp laceration. When the bone is denuded of periosteum, the development of granulation tissue and subsequent healing may be delayed, especially for large scalp defects. Nevertheless, granulation tissue growth over exposed bone may be facilitated by creating fenestrations on the exposed bone.[2] Instruments used to achieve this goal include a burr, chisel, bone drill, rongeur, and even scapel.[3] These tools allow for the rapid fenestration and selective abrasion of large areas of exposed bone. Then, the fenestration and abrasion create multiple bleeding points essential for the production of granulation tissue.[4] The de novo granulation tissue thus produced from both the Haversian canals and the wound edges allows the neogrowth through the holes to cover the skull bone. After the creation of bone fenestrations, granulation tissue usually appears within 1–3 weeks and continues over months at an average rate of 0.5 mm/day.[5]

In our case, the growth of granulation tissue continued at an average rate of 1.0 mm/day. Compared with other instruments, electric power drill may provide a more rapid method of fenestration for exposed cranial bone to stimulate granulation tissue; however, it depends on the surgeons' skill to control the depth of the drilling and minimize relative surgical complications. Care has to be taken not to drill into the brain, and the outer table of the calvarium is normally insensate and can be potentially done under local anesthesia in an adult.


  Conclusion Top


For the treatment of large-sized scalp lacerations, the “drill holes” procedure may be considered a safe, effective, and therapeutic alternative when the microsurgical repair is not feasible in low-resource settings.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bradford BD, Lee JW. Reconstruction of the forehead and scalp. Facial Plast Surg Clin North Am 2019;27:85-94.  Back to cited text no. 1
    
2.
Mohs FE. Chemosurgery. In: Microscopically Controlled Surgery for Skin Cancer. 2nd ed. Springfield, IL: Charles C Thomas Publisher; 1978. p. 26.  Back to cited text no. 2
    
3.
Drosou A, Trieu D, Goldberg LH. Scalpel-made holes on exposed scalp bone to promote second intention healing. J Am Acad Dermatol 2014;71:387-8.  Back to cited text no. 3
    
4.
Latenser J, Snow SN, Mohs FE, Weltman R, Hruza G. Power drills to fenestrate exposed bone to stimulate wound healing. J Dermatol Surg Oncol 1991;17:265-70.  Back to cited text no. 4
    
5.
Siegel DM. A new scalpel handle for the cutaneous surgeon. J Dermatol Surg Oncol 1989;15:1251.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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