Discussion:
Total scalp rupture is a serious injury because of its devastating effect on both the patient’s general health and aesthetics. However, this type of injury is considered to be of a rare occurrence and could mostly be encountered during industrial or high-speed road accidents. Our case had a ruptured scalp extending to the temporal and frontal bearing skin, the nasal bridge, and left ear’s auricle due to an electric bike accident. Most avulsed-scalp-related injuries are associated with hypovolemic shock and facial trauma. Despite that no signs of hypovolemic shock were clinically observed, prophylactic fluids administration was still ordered in emergency settings. In most similar injuries, a sole or combined injury of blood vessels could be encountered. This includes superficial temporal artery, supraorbital artery, occipital artery, and facial artery. These are rich arterial and venous arcades in the subcutaneous layer above the epicranial aponeurosis [4][5]. Therefore, these injuries should be treated first to evade the possibility of developing any surgical contraindication. Fortunately, we found no similar injures as our case showed an acceptable patient’s general condition. She was fully awake, self-aware, and there were no signs of secondary injuries. Usually, due to the extensive blood supply to the scalp, hemorrhaging of the scalp may appear profuse and should always raise suspicion of intracranial and cervical damage. Thus, patients should be examined thoroughly during the secondary survey by taking cervical spine and brain computed tomography to all patients in order to exclude surgical contraindications. As indicated in this case, test results proved no signs of cervical nor intracranial damage. Surgical replantation is the optimal treatment of the avulsed scalp that was first described by Miller et al in 1976 [6]. A successful replantation can well restore the hair-bearing aesthetic unit that is irreparable by other types of reconstruction [7]. Many surgical techniques were used for managing these types of skin defects usually depending on the defect size including microvascular surgery, skin grafts, and free flap techniques. Free flap techniques allow for reliable wound closure while providing a variety of reconstructive options. The most common flaps that are used to cover the scalp are radial forearm flap, latissimus dorsi free flap, serratus anterior flap, and anterolateral thigh flap [7].
Another method is presented by KHANDELWAL et al. (a successful use of hyperbaric oxygen therapy for a complete scalp degloving injury) [8], discussed a case of a 43-year-old female who presented with a complete scalp degloving injury, the result of a tractor powered take-off that caught her hair, after initial evaluation and stabilization, the patient underwent a microsurgical replantation procedure after 4 hours of her injury and lasted for 4 hours, during the procedure Only the superficial temporal arteries were re anastomosed with no venous anastomosis possible due to the extent injury of the scalp, the surgeons then administered Hyperbaric oxygen (HBO2) treatment at 2.5 atmospheres absolute (ATA) for 90 minutes after surgery due to duskiness of the flap, further HBO2 treatments were administered and a post-operative leech therapy for 10 days. At one-year follow-up the area of granulation tissue was reduced, with no detectable hair growth or nerve function. KHANDELWAL et al. showed in their case that the use of (HBO2) therapy could increase the chances of tissue survival.
The main reason we went for full-thickness graft is the lack of proper equipment at our hospital. Microvascular surgery, free flaps, or HBO2 therapy were all out of reach. Despite that, grafting appears to have great results when certain indications are considered.
Declarations •Ethics approval and consent to participate Ethical approval was given by the Aleppo University Hospital and the parent’s patient has given their Parental consent for this study •Consent for publication Written informed consent was obtained from the patient’s parent for the publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.  •Availability of data and material All data generated or analyzed are included in this article •Competing interests No conflict of interest exits in the submission of this manuscript. •Funding There were no funding •Authors’ contributions all authors have read and approved the manuscript MBA : Lead in writing and reviewing the manuscript SS, AH, AA, AN, BZ, AE :Contributed in writing the manuscript. •Acknowledgements Our sincere thanks to all the doctors and nurses who participated in the treatment of this case, and we also thank the patient’s parents for allowing us to reports this case.