[Surgical management of cutaneous and musculoskeletal complications in fulminant sepsis].
BACKGROUND
Surgical management of purpura fulminans is required as in the acute as in the sequelae period. A retrospective case review of these sequelae, procedures which have been performed in the different moments and the outcomes was undertaken.


METHODS
We reviewed retrospectively 13 patients treated in our hospital from 1993 to 2003. 8 males and 5 females, with a median age of 2 years old (4 days-14 years) were managed. 70% were meningococcical. The most common areas were low extremities (92%), upper extremities (76%), lips (n=1), nose (n=1) and genitalia (n=1). Most of cases were bilateral (n=11) although two patients presented isolated affectation in one of the extremities. The procedures were classificated depending on the surgical moment. Clinical follow-up was attempted on all surgical patients; we evaluated the aesthetic, functional and psychosocial outcomes.


RESULTS
One child died along the first 24 hours; 11 required early surgery and all of them required late interventions. 50% in the serie had necrosis over 15%. In Intensive Care Unit, it was necessary to do 6 fasciotomies (extirpating muscle in 2) and escharectomies and debridements in 8. Early amputations were made in 2 patients: both of them required ampliation in the following days. The cutaneous defects were covered with skin allografts and artificial dermis. During the sequelae period, 8 amputations were necessary (the four extremities in one case). Other procedures were coverage with autologous skin grafting (n=7), Zplasties, Wplasties (n=5), myocutaneous flaps (n=3), release of contractures (n=3) and osseus resection (n=5). There were skeletal growth disturbances which were managed with osteotomies (n=3), realineations(n=3), application of Ilizarov (n=2) and Hoffman (n=2) frames; Nowadays, 6 patients have a complete independent functionning with the use of orthotics (n=3) and prosthetics (n=3)


CONCLUSIONS
The pediatric surgeon has an important role in management and prevention of complications in patients with purpura fuminans. Urgent actuation and close follow-up decreases the morbidity; furthermore, the early reparation of sequelae improves their adaptation in school, in the family and in the society despite the physical disability.
Andrés
A M
AM
Departamento de Cirugía Pediátrica, Hospital Universitario La Paz, Madrid. aneandresmo@hotmail.com
López Gutiérrez
J C
JC
Rivas
S
S
De la Varga
A
A
Ros
Z
Z
Díaz
M
M
López Cabarcos
C
C
Tovar
J A
JA
D000208:Acute Disease; D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007234:Infant, Premature; D008297:Male; D008589:Meningococcal Infections / Q000453:epidemiology*; D009140:Musculoskeletal Diseases / Q000453:epidemiology* / Q000601:surgery*; D012189:Retrospective Studies; D012871:Skin Diseases / Q000453:epidemiology* / Q000601:surgery*; D018746:Systemic Inflammatory Response Syndrome / Q000453:epidemiology*