ANDREW L . WEINSTEIN, M.D.MARCH 24 , 2014

Degloving Injuries

What is a degloving injury?

A type of avulsion in which an extensive section of skin is completely torn off the underlying tissue, severing its blood supply

So-called for its resemblance to removing a glove

Initial evaluation

Great force (MVC, industrial, agricultural) serious co-injury to other organ systems

Treat life-threatening injuries before proceeding to evaluation and treatment of extremity injury, which itself is rarely life-threatening

ATLS Primary survey

Airway maintenance with cervical spine protection Breathing and ventilation Circulation with hemorrhage control Disability/neurologic assessment Exposure and environmental control

Secondary survey

Initial evaluation: “when, where, how”

When: Longer duration = greater risk for

infection (>6h precludes primary closure or immediate coverage)

Sensitivity to ischemia (muscle, 4-6h > skin > bone)

Temperature (12-24h viability of devascularized tissues if cooled)

Where Farming = highly contaminated

(aggressive debridement, precludes primary closure or immediate coverage)

How Force of injury = extent of tissue

necrosis or “zone of injury” (aggressiveness of approach, removal of foreign bodies, compartment syndrome)

Physical exam and work-up

Vital signs

HPI: wound contamination/tetanus status

Physical exam: neurovascular, musculoskeletal

Plain films, scans

Labs: CBC, BMP (K), T&S, CK, UA, EKG

A note about capillary refill and nerve findings

Nail bed capillary refill unreliable indicator of peripheral perfusion (stagnant blood in devascularized digit)

More reliable is dorsal paronychial tissue on side of nail

Most reliable indicator is color of blood that oozes from tissue after needle prick (bright red vs. purple)

For major vessels, use handheld Doppler probe

Nerve can remain physically intact after crush/avulsion injury, yet axons may still be damaged Neuropraxia vs. axonotmesis

Initial debridement

Single most important stepIf inadequate and nonviable tissue left behind

Infection Further tissue loss Potential loss of limb or life

If skin does not bleed or oozes only dark blood at the time of initial surgery, must debride to create healthy soft tissue bed for reconstruction

If wound is heavily contaminated or involves critical areas where viability uncertain, repeat OR debridement 24-48h later

Initial debridement cont’d…

Although early wound closure desirable, often prudent to delay definitive coverage until wound stable (e.g. reduced contamination)

Serial debridement separated by 24-48h to reduce infection and optimize healing and motion

Aim for definitive coverage by 7-10d with in interim keeping vital structures moist

As swelling develops after injury, tendency for wounds to enlarge making closure more difficult

Wound reduction

“Vessel loops” Crisscross fashion with staples

along wound edge to create “corset effect”

Brings wound together without ischemia, avoids compartment syndrome

NPT/VAC = “mechanical fibroblast” Removal of exudate, decrease in

edema, closure of dead space, promotion of wound contraction, and promotion of granulation

Wound contracts and granulates, covered with skin graft rather than complex flap

VAC: special considerations

Closed system change sponge q3-5d or more frequently depending on level of contamination

Revolutionized approach to soft tissue coverage in complex lower extremity defects

Should NOT be used for extremities with Severe contamination Infection Significant bleeding Caution in setting of vascular

repair or reconstruction

Soft tissue coverage

Goal: achieve healed wound with stable, durable coverage and vascularized tissue over critical structures

Determines environment in which all other repaired and reconstructed structures will heal and function

Coverage should be low profile and supple over mobile areas such as joints

Reconstruction

The simplest method of coverage appropriate to the situation to achieve optimum form and function Secondary intention Primary closure Skin grafting

STSG FTSG

NPT/VAC Flap

Local Distant Free

Additional considerations for surgery

Patients health Age, CV/pulmonary disease, bleeding tendencies, DM

increase risk of perioperative complication or even mortality

Consider simplifying the method of reconstruction

Smoking or use of vasoactive drugs (e.g. cocaine) is relative contraindication for complex microvascular reconstruction

Healing by primary and secondary intention

Primary closure or delayed primary closure (<5-7d) should be performed whenever possible

Wounds closed loosely so tension ≠ ischemia

If wounds cannot be closed primarily may be allowed to heal secondarily (more appropriate with smaller defects)

Skin grafts

For larger, noncritical defects Autograft (from patient) Allograft (cadaveric)

May revascularize and “take,” but then rejected <1w Promote vascular ingrowth into wound bed in

preparation for autografting Xenograft (usually porcine skin)

Primarily as a “biologic dressing”

Autograft: STSG (meshed vs. unmeshed) vs FTSG

Skin Grafting

Split-thickness skin grafts (STSG) Thinner, more easily revascularized ,

better take, more resistent to infection Meshed vs. unmeshed

hematoma/seroma, infection, appearance

Donor sites: lateral thigh, buttocks

Bolster dressing or VAC x5d

Full-thickness skin grafts (FTSG) Contracts less, more durable and

flexible, better sensation Areas prone to shear and load:

fingertips, palms, web spaces and joints Donor sites:

groin crease, abdomen (hypothenar skin for hand defects)

Bolster dressing only

Case Report #1

Management of a circumferential lower extremity degloving injury with the use of vacuum-assisted closure. Wong LK, Nesbit RD, Turner LA, Sargent LA. South Med J. 2006 Jun;99(6):628-30.

A 58-year-old male presented with a large circumferential degloving injury and was immediately taken to the operating room for further assessment of his wound. At that time, a plastic surgeon was consulted to manage the wound due to its size and significant soft tissue loss. The decision was made to manage the patient's wound with the vacuum-assisted closure (VAC) device to prepare the wound bed for grafting. After three weeks of VAC therapy, the wound bed was revascularized with granulation tissue and was ready for grafting. The patient underwent a successful split thickness skin graft on hospital Day 23 and was discharged home. Follow-up visits revealed no scar contracture or functional limitations.

Case Report #2

Circumferential application of VAC on a large degloving injury on the lower extremity. Barendse-Hofmann MG, van Doorn L, Steenvoorde P. J Wound Care. 2009 Feb;18(2):79-82.

Full healing was achieved following the circumferential application of VAC therapy to prepare a large lower-extremity wound involving both soft-tissue injury and femoral fractures for grafting.

Flaps

Flaps contains their own blood supply vs. graft, which require vascularization from wound bed

Complex wounds with exposed “white structures,” wounds over joints or web spaces or those at risk of compromising function because of scarring or contracture

Axial flaps: pedicled vs. free Harvested from outside zone of

injury e.g. ALT, RFF

Postoperative Management/Rehab

If skin graft used, must prevent motion or shearing beneath graft for 5-7d to allow for take, then patient may wash with soap and water and apply lotion

Early institution of therapy and rehab critical to achieve optimal functional outcome, injured tissues become less pliable in a matter of days after injury

Secondary Procedures

Goal: improve motion, sensibility, durability, contour (e.g. flap debulking)

Should be delayed until soft tissues have matured and softened which can take 3-6 mos

Exception: bone/nerve grafting performed at 4-6w

Complications

Failure to adequately debride devitalized tissue, especially deep muscle, can have devastating consequences Myoglobinuria, hyperkalemia, necrotizing soft tissue infection, limb loss,

generalized sepsis, and death Second/third “look”: tissue that may not have initially appeared

devitalized may become so as a result of the inflammatory response to injury during this period

Soft tissue infection Wide, open drainage and debridement to arrest progression

Osteomyelitis Complete debridement of devitalized infected bone to healthy bleeding

bone and vascularized soft tissue coverageOther common complications

Hypertrophic scarring, joint contractures, tendon adhesions, neuromas, and soft tissue ulcerations all of which may be addressed by secondary procedures.

Compartment Syndrome

High index of suspicion should be maintained

Signs/symptoms – 5 P’s Pain, with passive stretching out of

proportion to physical findings Paresthesia Pallor, pale and shiny skin distal to

injury Paralysis, late finding Pulselessness, late finding

Confirmed with direct measurement of pressure in the muscle compartment

Compartment syndrome emergent decompression

Summary

Priority is stabilization of patient: ABCDEInitial operation sets stage for all that will

followComplete debridement of devitalized tissue± vessel loops/VACSoft tissue coverage by reconstructive ladderSkin graft vs. flap Anticipating complicationsRehabilitation and secondary procedures