Degloving soft tissue injuries of upper limbs and their management in Khartoum – Sudan: a cross-sectional study

Abstract

Background:

Degloving soft-tissue injuries are underreported in Sudan and are potentially devastating. They require early recognition and diagnosis with early and systemic management to reduce the complications that may arise, and to minimize delay for proper intervention by a multidisciplinary team that is usually needed to ensure the effective rehabilitation of these patients and a better outcome.

Objective:

To assess the degloving soft tissue injuries of the upper limb and their management in Khartoum.

Material and methods:

A cross-sectional hospital-based study is multicentric (Khartoum North Teaching Hospital, Association Specialized Hospital, East Nile Hospital) in Khartoum – Sudan. A study was conducted on 82 patients with degloving soft tissue injuries of the upper limbs during the period from 2021 to 2022. Patients with different age groups were included whereas patients with close degloving injuries and degloving injuries of fingers were excluded.

Results:

Eighty-two patients were studied. The male-to-female ratio was 4.8:1, with a mean age of 31.5. The common (59.8%) injury site was the dominant upper limb, with 58.5% distal UL injuries. The main etiology of injury was road traffic accidents (52.4%), followed by occupational injuries (20.7%). 51.2% of the injury was a noncircumferential single-plane degloving soft tissue injury. Degloving soft tissue injuries of the upper limbs are associated with deep structure injuries in 61% of patients (bone fracture in 43.9%). Serial debridement before reconstruction as a staged procedure was done in 61% of patients. The most common reconstruction method performed was skin grafts (57.3%), followed by flaps (32.9%). Half (52.4%) of the patients developed complications postoperatively, and the most frequent complication was wound infection (23.1%).

Conclusion:

Upper limb degloving soft tissue injuries are complex life-threatening injuries that, if present late or poorly managed, lead to devastating complications ranging from local infection to major disabilities, amputation, and death.

Introduction

Highlights

• Degloving injury is a serious common dilemma affecting the limbs and leads to significant morbidity and even death.

• Upper limb degolving injuries underrated beside improperly management and outcome will negatively affect the functional aspect of the limb.

• Deferent reconstructive methods can be applied to achieve esthetic and functional satisfactions.

Degloving soft tissue injuries (DSTI) consist of avulsion injuries in which an extensive portion of the skin and subcutaneous tissue are completely separated from the underlying fascia and deeper structures. These injuries are high-power injuries that result most commonly from road traffic accidents. Industrial and agricultural accidents, machinery injuries, and ring avulsions are other causes of degloving injuries. DSTI occurs mostly in young males since their daily activities make them more at risk of trauma than females and children. The mean age is 28.8 years, with a male-female ratio of 2:1^1–4.

Although any part of the body can have degloving soft-tissue injuries, the upper limbs are the most challenging, with improper management, they lead to high rates of morbidity and eventually mortality. Upper limb degloving injuries may lead to bleeding and, subsequently, hemodynamic instability. Degloving injuries in children can be serious and may require more complex surgical interventions. The aim is to restore the function of the distorted part of the body⁵. Degloving injuries can be uniplanar or multiplanar. Uniplanar is when the degloving injury occurs between the subcutaneous fat and deep fascia, while multiplanar occurs when tissues are disrupted within muscle groups and between muscle and bone. Therefore, multiplanar degloving injuries represent a much more severe group. Trans-muscular and intermuscular perforating vessels are damaged by the trauma, leading to skin necrosis. This process of necrosis of the degloved tissues may progress. Venous congestion and infiltration of inflammatory cells may contribute, and hematoma may form as part of the pathology, producing proinflammatory cytokines and free radicals. Salvaging the skin with hematoma evacuation may occur, but the important part of treatment is to debride the devitalized tissue and eventually reconstruct it⁶.

Management of major degloving injuries in the upper limb is an endeavor, primarily due to their rarity and the absence of definitive surgical protocols and informed decision-making frameworks. A range of reconstruction strategies have been applied internationally with effective outcomes, including revascularization techniques aimed at salvaging degloved skin, defatting and reattachment of the avulsed flap, and the use of vacuum-assisted closure (VAC) therapy. Traditional methods such as primary closure, skin grafts, and flap surgeries are also commonly employed^7–10.

With the unavailability of safety measures in hazardous occupations and the abundance of road traffic accidents in Sudan, there is a lack of data concerning upper extremity degloving soft tissue injuries. More studies need to be undertaken to outline the presentation and treatment approach of these cases for a better outcome and less complication. The purpose of this investigation is to present information regarding the management of upper limb degloving soft tissue injuries in Sudan. This study aspires to assist in the formulation of management protocols that can be applied in resource-limited settings.

Material and methods

A multicentric cross-sectional study was conducted in Khartoum, Sudan, involving three hospitals: Khartoum North Teaching Hospital, Association Specialized Hospital, and East Nile Hospital. The research focused on 82 patients suffering from degloving soft tissue injuries of the upper limbs between 2021 and 2022. Participants were categorized by age into five groups: under 15 years, 15–30 years, 31–45 years, 46–60 years, and over 60 years. Patients with closed degloving injuries, finger degloving injuries, and those in critical condition were excluded from the study, as closed injuries typically present later and are prone to misdiagnosis, leading to delays in treatment. Established protocols are available for managing finger degloving injuries, while the primary concern for critically ill patients remains life preservation. Furthermore, the approach to managing degloving injuries may vary based on the severity of the patient’s overall health. The mechanism and site of injury were identified as road traffic accidents, work-related accidents (e.g. industrial and farm-related), falls from a height, and falls of a heavy object. The pattern of degloving was classified using a classification system that describes four patterns of degloving: 1. localized degloving, 2. noncircumferential, single-plane degloving, 3. the single plane, circumferential degloving, and 4. circumferential and multiplanar degloving. Furthermore, the evaluation of the associated deep structure injuries (muscles, bones, vessels, and nerves) was conducted. The period between injury and presentation was divided into 24 h, 1–3 days, 3–10 days, and >10 days.

In managing degloving injuries surgically, all patients underwent evaluation based on the Advanced Trauma Life Support (ATLS) protocols and the Injury Severity Score (ISS). Systemic antibiotic therapy was promptly initiated upon recognizing the degloving injury, with a focus on covering skin flora through the use of cefazolin, thereby minimizing the potential for infection. Antibiotic treatment commenced within 3 h of the injury and was maintained for a period ranging from 1 to 3 days. The debridement process was performed under a tourniquet to improve visibility, and the viability of the wound edges was assessed after the majority of the tissue excision was completed. Reconstruction options included primary closure, split or full-thickness skin grafts, and various flap techniques, such as local, regional, or distant flaps. Early postoperative complications included infection, skin necrosis, dehiscence, bleeding, hematoma, and graft loss.

A revised questionnaire, which included the previously identified variables, was distributed by the researcher to patients, alongside data obtained from hospital records. Each patient was observed for 6 months postsurgery to assess the outcomes. The data analysis utilized the Statistical Package for the Social Sciences (SPSS), with a significance level set at a P-value of less than 0.05. Ethical approval was granted by the Educational Development Center (EDC) of the Sudan Medical Specialization Board and the hospitals involved in the study. Patient confidentiality was strictly maintained, and data collection was conducted only after providing a detailed explanation of the study’s objectives and securing informed written consent. The work has been reported in line with the strengthening the reporting of cohort, cross-sectional, and case–control studies in surgery (STROCSS) criteria¹¹.

Results

A total of 82 patients with upper limb degloving soft tissue injuries were included in this study. The male-to-female ratio was 4.8:1 (Fig. 1). The ages of the patients ranged between 8 and 75 years with a mean age of 31.5 years (Table 1). Forty-nine (59.8%) patients were injured in their dominant limb (Table 2).

Figure 1.

Demonstrates sex of patients with upper limb DSTI.

Table 1.

Shows the age distribution of the patients with upper limb DSTI

Age	Frequency (Percent)
<15	13 (15.9%)
15–30	30 (36.6%)
31–45	23 (28.0%)
46–60	12 (14.6%)
>60	4 (4.8%)
Total	82 (100.0)

Table 2.

Shows the frequency of dominant limb injury among UL DSTI patients

	Frequency (Percent)
Both	1 (1.2%)
Dominant limb	49 (59.8%)
Nondominant limb	32 (39.0%)
Total	82 (100.0)

The mechanism of injury was road traffic accidents in 43 (52.4%) of UL DSTI patients followed by occupational injury in 17 (20.7%) patients, gunshot injury in 9 (11%) patients, sharp object in 6 (7.3%) patients, domestic injuries in 5 (6.1%) patients, one blunt trauma patient (1.2%), and another patient fall from a height (1.2%) (Table 3).

Table 3.

Shows the frequency of each mechanism of injury among UL DSTI patients

	Frequency (Percent)
Blunt trauma	1 (1.2%)
Domestic injury	5 (6.1%)
Fall from height	1 (1.2%)
Gunshot injury	9 (11.0%)
Occupational injury	17 (20.7%)
Road traffic accident	43 (52.4%)
Sharp object	6 (7.3%)
Total	82 (100.0)

Thirty-six (43.9%) patients had DSTI of the dorsum of the hand, while 32 (39%) patients had degloving injury of the forearm, 15 (18.3%) patients had an injury to the palm of the hand, 14 (17%) patients had an injury to the wrist, while 11, 9, and 3 (13.4, 11, and 3.6%) patients had an injury to the arm, elbow, and shoulder, respectively. Twenty-nine (35.3%) patients of them had multiple site injuries in their upper limbs.

The patterns of DSTI in the upper limb and noncircumferential single plane degloving injury were seen in 42 (51.2%) patients, while localized degloving injuries were seen in 32 (39%) patients. Whereas circumferential single-plane injuries were seen in five (6%) patients, and circumferential multiplane injuries were seen in three (3.6%) patients (Fig. 2).

Figure 2.

Demonstrates the frequency of different patterns of UL DSTI.

Deep structures injuries were associated with degloving soft tissue injury in 50 (61%) patients, in the form of bone fractures in 36 (43.9%) patients, tendon injuries in 4 (41%) patients, nerve injuries in 14 (17%) patients, and vascular injuries in 10 (12.1%) patients (Table 4).

Table 4.

Shows the frequency of each structure injury associated with UL DSTI

	Count
Tendon injury
Yes	34
No	48
Nerve injury
Yes	14
No	68
Vascular injury
Yes	10
No	72
Bone injury
Yes	36
No	46

The time between injury and presentation was less than 24 h in 22 (26.8%) patients, 24–72 h in 22 (26.8%) patients, 3–10 days in 15 (18.3%) patients, more than 10 days in 23 (28.04%) patients (Table 5).

Table 5.

Shows the time between injury and presentation among UL DSTI patients

	Frequency (Percent)
<24 h	22 (26.8%)
1–3 days	22 (26.8%)
3–10 days	15 (18.3%)
>10 days	23 (28.0%)
Total	82 (100.0)

Debridement and soft tissue reconstruction as a single procedure was performed in 24 (29.3%) patients, whereas serial debridement prior to soft tissue reconstruction as a staged procedure was performed in 50 (61%) patients, debridement and primary closure was performed in 8 (9.8%) patients (Fig. 3).

Figure 3.

Demonstrates the frequency of patients undergoing different management approaches of UL DSTI.

The reconstruction method used was skin grafts in 47 (57.3%) patients in the form of STSG from a donor site in 30 (36.5%) patients and FTSG from a donor site in 8 (9.7%) patients. While FTSG and STSG from degloved skin were performed in two and one (2.4% and 1.2%) patients, respectively. Negative pressure wound therapy with STSG was performed in 6 (7.3%) patients. Flaps were used in 27 (32.9%) patients in the form of a locoregional flap in 13 (15.9%) patients ( radial artery forearm flap in five (6%) patients, first dorsal metacarpal artery flap in three (3.7%) patients, rotational, bipedicle, lateral arm, posterior interosseus artery, and ulnar artery forearm flap in one patient each), distant flap in 12 (14.6%) patients (Groin flap in 8 (9.7%) patients, LD flap in four (4.8%) patients and TFL flaps in 1 patient), free flap (ALT free flap) was used in two (2.4%) patients. Primary closure was done in eight (9.7%) patients.

Early postoperative complications were seen in 43 (52.4%) patients in the form of wound infection and 19 (23.1%) patients, skin/flap necrosis in 14 (17%) patients, wound dehiscence in 10 (12.1%) patients, bleeding and hematoma in four (4.8%) patients and graft loss in three (3.6%) patients.

Twenty-nine (58%) of patients who had associated deep structures injuries developed early complications (statistically significant, P=0.018).

Twenty-four (66.6%) of patients with bone fractures had early postoperative complications (statistically significant, P=0.002), in the form of wound infection 14 (38.8%) patients (P=0.003), skin/flap necrosis 10 (27.7%) patients (P=0.023). Bone fractures were significantly associated with long hospital stays in 13 (36.1%) patients (P=0.014), In patients managed with a single debridement, 24 (75%) of patients had complications. While serial debridement performed in 15 (30%) of patients developed complications (statistically significant, P=0.000).

Five (22.7%) patients who presented less than 24 h from the time of injury developed complications, 18 (48.6%) patients presented after 24 h and up to 10 days, and 16 (69.5%) patients presented after 10 days (statistically significant, P=0.019) (Table 6).

Table 6.

Correlation between time from injury to presentation with early postoperative complications in UL DSTI patients

	complications
	Yes	No
The time between injury and presentation
<24 h	5	17
1–3 days	9	13
3–10 days	9	6
>10 days	16	7

^*The χ ² statistic is significant at the .05 level.

Discussion

Eighty-two patients with upper limb degloving soft tissue injuries were analyzed in this study. The sample showed the male to female ratio of 4.8:1, Velazquez et al.¹² showed over 75% of injured patients were men with a male-to-female ratio of 3:1, while Mutiso et al.¹³ in Kenya reported a male-to-female ratio of 1.5:1. This might be because of male predominance in the working sector in our population.

The ages of patients ranged between 8 and 75 years with a mean age of 31.5 years at the time of injury. This was confirmed by the results of Velazquez et al.¹² where the mean age of patients was 37 years, compared with the study conducted in Qatar the mean age of patients was 30.5±12.8 years¹⁴.

Forty-nine (59.8%) patients were injured in their dominant limb, the same result was obtained in Pakistan where over half of the study subjects (57.5%) were injured in their dominant hands¹⁵.

A road traffic accident was the leading cause of injury in 43 (52.4%) of UL DSTI patients; it is more frequent compared to the Chinese study, where traffic-related injuries were 40.62%¹⁶. This may be due to poor traffic management and adherence to traffic rules in Sudan. Followed by occupational injury in 17 (20.7%) patients, in comparison to a study done in Kenya, 43.7% were work-related injuries¹³, whereas in other studies there were no reported work-related injuries among DSTI patients¹⁴. This discrepancy in frequencies could be related to the lack of work safety equipment among hand-related job workers and the unavailability of occupational health facilities in Sudan. Gunshot injuries were found in nine (11%) patients, sharp object injuries in six (7.3%) patients, and domestic injuries in five (6.1%) patients, while the remaining two patients were injured by blunt trauma and a fall from a height. The latter etiology of injury showed a higher rate in a hospital-based study in Qatar, where patients were estimated as 12.9%⁶, this might be due to the abundance of local high-rise buildings in Qatar. The other mechanisms of injury reported in our study were not common in the literature, which might be because of the increasing rate of security problems and violence in Sudan.

Regarding the anatomical sites of UL DSTIs, the most frequent (48 (58.5%) patients) were distal UL injuries (hand and wrist), followed by middle UL injuries (forearm and elbow) in 35 (42.6%) patients, 13 (15.8%) patients had an injury to the proximal UL (arm and shoulder), and 29 (35.3%) patients had multiple site injuries in their upper limb. This order of frequency was reported by Alberto et al.¹⁷, who reported that injuries from proximal to distal were shoulder and armpit (2.5%); arm and elbow (12.9%); forearm (17.2%); fist and hand (67.2%). Distal UL was the commonest, this could be due to the accidents attained during hand-related jobs with a lack of usage of safety equipment.

Regarding the patterns of DSTI in the upper limb, the majority of patients, 42 (51.2%), had noncircumferential single plane degloving injury, followed by localized degloving injuries seen in 32 (39%) patients. Circumferential single-plane injuries were seen in five (6%) patients, and circumferential multiplane injuries were seen in three (3.6%) patients. In a study done in 2021 with similar results, the most frequent were noncircumferential single plane degloving (59.09%), while circumferential injuries were 27.27%¹³.

Deep structure injuries were associated with degloving soft tissue injuries in 50 (61%) patients in the form of bone fracture in 36 (43.9%) patients, which is similar to the study done by Mutiso et al.¹³ where deep structure injuries associated with degloving injuries were reported in 54.5%, of those bone fractures constituted 18.19% of the cases. Our study showed a higher rate of bone fracture compared to this study, mostly due to high energy injury (RTA) being the main etiological factor of UL DSTIs with a higher rate of accidents than in other studies, tendon injuries were seen in four (41%) patients, nerve injuries were seen in 14 (17%) patients and vascular injuries were seen in 10 (12.1%) patients which is similar to a study published in occupational related injuries with a rate of 15 and 12.5%, respectively¹⁵.

A minority (22 (26.8%)) of patients presented less than 24 h from the time of injury, whereas 22 (26.8%) patients presented within 24–72 h, 15 (18.3%) patients presented within 3–10 days, and 23 (28.04%) patients presented after 10 days. Compared to a study conducted in Western Kenya almost double (62.5%) of DSTI patients presented in less than 24 h from the time of injury while 37.5% were present after 24 h¹³. This late presentation of patients related to poor health care facilities, access to medical care, and health education, in addition to the plastic surgery department not being the primary treating unit.

Debridement and soft tissue reconstruction as a single procedure was performed in 24 (29.3%) patients, serial debridement before soft tissue reconstruction as a staged procedure was performed in 50 (61%) patients, debridement and primary closure was performed in 8 (9.8%) patients. Similarly, a prospective study conducted in Sub–Saharan Africa showed that serial dressing was the most common therapeutic practice of overall degloving injuries, followed by primary debridement and closure of the avulsed flap (76.47 and 37.25%, respectively)⁴.

Regarding the reconstruction method used, primary closure was done in eight (9.7%) patients, and skin grafts constituted 47 (57.3%) of patients. The frequency of STSG was higher (30 (36.5%) patients) than FTSG (8 (9.7%) patients). In a study conducted in Brazil, reconstruction procedures included 29 (25%) skin grafts out of 116 cases¹⁷. Almost half of the skin grafts were done in Khartoum. This is mostly due to the lack of experienced personnel that patients present to and the fact that management by using skin grafts is an easier approach than technically demanding flaps. FTSG and STSG from degloved skin were performed in 2 and 1 (2.4 and 1.2%) patients, respectively, and negative pressure wound therapy with STSG was performed in 6 (7.3%) patients. This rate is far lower compared to Velazquez et al.¹² results that stated utilization of the avulsed tissue in reconstruction was 71.6% of cases and an estimated 86.5% of patients had negative pressure wound therapy. The low local rate of avulsed tissue usage is probably due to the high infection rate among DSTI patients and delayed presentation of patients leading to skin necrosis making the avulsed flap unsalvageable. The challenges associated with low-rate negative pressure wound therapy could stem from the high costs of the devices and their limited accessibility.

Flaps were used in 27 (32.9%) patients in the form of a locoregional flap in 13 (15.9%) patients ( radial artery forearm flap in 5 (6%) patients, first dorsal metacarpal artery flap in three (3.7%) patients, rotational, bipedicle, lateral arm, posterior interosseus artery, and ulnar artery forearm flap in one patient each), distant flap was used in 12 (14.6%) patients (Groin flap in 8 (9.7%) patients, LD flap in four (4.8%) patients and TFL flaps in one patient), Free flap (ALT free flap) was used in two (2.4%) patients. Compared to a study published in PRS Global Open, 21% required flap reconstruction¹². In a study conducted in Brazil, 5.17% of patients had advancement flaps; 6.03% rotation flaps; 28.4% pedicled fasciocutaneous flaps (22.4% groin flap; 3.4% posterior interosseous artery flaps; 2.58% radial forearm flaps), 4.3% latissimus dorsi muscle flaps, 2.5% serratus anterior muscle flap, and 18.1% free flaps (parascapular, lateral arm flaps, and neurovascular free flaps)¹⁷. In comparison to the former study, the frequency of flaps as a reconstructive method was similar. However, the type of flaps and their frequencies in the latter study revealed that the rate of the free flaps is much lower in our patients, donated to the limited facilities for microsurgical procedures in Khartoum, owing to the significant decrease in the rate of magnification use in this study. Serratus anterior muscle flap is not commonly used here (not the primary choice). On the other hand, advancement flaps are mostly utilized in finger injuries rather than other parts of the upper extremity, which are excluded in this study. The rest of the flaps were performed at different rates, with the groin flap being the most popular due to the high rate of distal UL injuries in this study which is mainly reconstructed using this flap.

Early postoperative complications were seen in 43 (52.4%) patients in the form of wound infection in 19 (23.1%) patients, skin/flap necrosis in 14 (17%) patients, wound dehiscence in 10 (12.1%) patients, bleeding, and hematoma in 4 (4.8%) patients and partial graft loss in 3 (3.6%) patients. Comparing the results to the study in DSTIs by Mutiso et al.¹³, analyzing frequencies of early complications included local wound infection in 40%, hemorrhage in 26%, graft failure in 20%, and primary flap necrosis in 13.3%. Empirical antibiotics targeting both gram-negative and gram-positive bacteria were administered immediately upon the patient’s arrival at the hospital, as part of the secondary survey. This antibiotic treatment was maintained until the patient was discharged. There is no established guideline for the administration of antibiotics in the case of degloving injuries. Therefore, each institution evaluates the use of antibiotics based on the expertise of microbiologists and clinical pharmacists, along with the patient’s symptoms. Major degloving injuries required dressing changes to be performed under anesthesia in a sterile environment, while minor injuries had their dressing changes conducted in the outpatient clinic under clean conditions. These elements are all related to the risk of postoperative wound infections. These different complication rates may be due to the delayed presentation of patients to plastic surgery units. Initially, patients are reviewed at the emergency and orthopedic departments, where they are diagnosed and primarily managed; therefore, hemorrhage is less frequently detected by the plastic surgery team. The graft failure rate is lower than that indicated in the Mutiso et al. study, which is connected to the lower infection rates. Another study reported similar results, showed an overall local wound infection rate of 20%, necrosis of the repositioned skin or flap of 7.5%, and unsatisfied skin graft take of 7.5%⁴.

Over half (29 (58%)) of patients who had associated deep structure injuries developed early complications (statistically significant, P=.018). Twenty-four (66.6%) patients with bone fracture had early postoperative complications (statistically significant P=.002), in the form of wound infection in 14 (38.8%) patients (P=.003). A prospective observational study showed that degloving injuries with underlying fractures had increased risk (32.5%) of poor outcomes, mainly infection in 15%⁴. This high incidence of infection among DSTI patients associated with fractures might be due to the contaminated nature of the wound that requires early wash and debridement and the delayed management of fractures by the orthopedic team (poor multidisciplinary team approach).

When complications were compared to treatment modalities, there was a statistically significant association (P=.000) between patients who had single-stage debridement and reconstruction or multistage serial debridement and reconstruction and developing early complications in 24 (75%) and 15 (30%) patients, respectively. Most of the patients who were treated with single debridement and reconstruction in one session had complications. This was similar to a study, reported in a neighboring country, in which seven (46.7%) patients were treated with serial debridement and developed complications¹³. Another study showed that four out of seven patients (57%) developed recurrence and needed the procedure again, with primary debridement and closure being the main interventions used¹⁸.

This concludes that rushing to reconstruct a dirty wound increases the risk of complications. In addition, it may be due to improper radical debridement and the low-rate of magnification use leads to an increased rate of complications in patients who undergo single debridement and reconstruction as a single procedure.

More than two-thirds of 16 (69.5%) patients presented after 10 days from the time of injury developed complications (statistically significant, P=.019). This was reported by a Russian researcher who confirmed that failures in treatment were mostly observed in patients admitted for treatment after 5 days of injury¹⁹. In another study included 40 patients 29 of them had complications 16 (55.1%) of them presented late >12 h²⁰.

Conclusion

Upper limb degloving soft tissue injuries represent intricate and potentially life-threatening conditions. If these injuries are not addressed promptly or managed effectively, they can result in severe complications, including local infections, significant disabilities, amputations, and even fatalities. The findings of this study indicate that these injuries predominantly arise from inadequate traffic management, insufficient use of safety equipment in hazardous hand-related occupations, and a lack of accessible healthcare services and skilled professionals to treat these injuries. Given that wound infection is the most prevalent complication, it is crucial to implement guidelines for antibiotic administration and enforce strict protocols to maintain an aseptic environment in surgical settings. Furthermore, this study highlights the urgency of this issue and suggests preliminary strategies to establish effective management practices, which may ultimately decrease morbidity rates.

Ethical approval

Ethical consideration:

• Ethical clearance was obtained from the ethical committee of the SMSB and corresponding authorities.

• Approval was obtained from hospital administration.

Consent

The consent statement in the author form is not suitable. Please include the following: written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Source of funding

Not applicable.

Author contribution

I confirm that all the authors have made a significant contribution to this manuscript, have seen and approved the final manuscript and have agreed to its summation. Also I accept full responsibility for the work and the conduct of study, have access to data, and controlling the decision of publishing.

Conflicts of interest disclosure

The authors declare no conflicts of interest.

Research registration unique identifying number (UIN)

No involvement of human subjects or experimentation.

Guarantor

Sara Ali. Tel. +249 96 586 9799. E-mail: sarabagdadi50@gmail.com

Data availability statement

Data available.

Provenance and peer review

Not been published before.