THE SKIN HAND - Postgraduate Medical Journal · 453 THE SKIN OF THE HAND The Immediate Treatment of...

453

THE SKIN OF THE HANDThe Immediate Treatment of Crush Injuries and Lacerations

BA7 JOHN N. BARRON, F.R.C.S.(Ed.)

IntroductionThe importance of the surgery of the hand

has been unfortunately under-estimated in thepast. This lack of systematic teaching on thesubject is reflected in general practice and theresults of such treatment provide a dis-tressingly large number of patients who re-quire lengthy reconstructive procedures.

Since the incidence of injury falls mostheavily upon the fit and able worker, it isobviously most important to concentrateattention on this vital problem.

Principles of TreatmentA thorough knowledge of the minute

anatomy and the function of the hand is theonly basis for correct diagnosis and treatment.Much of hand surgery is the surgery ofmillimetres, and the operator should be pre-pared to equip himself to this degree ofintimacy with its structure and its function.

Atraumatic TechniqueThe response of the tissues to a crushing

injury is oedema and fibrosis, degenerationand cicatrix. This is just as true of thelocalized crush of a haemostat as it is of apower-press injury and varies only in degree.Multiple small crushing traumata at operationmay cause a widespread vascular protest, withits inevitable sequence of oedema and fibrousreplacement.So narrow is the margin of play betveen a

tendon and its sheath and so intimate thestructure of a capsule and its ligaments, thateven a minor invasion by 'the fibroblast mayimpair dexterity and function. It is well,then, at operation to limit the necessarytrauma so that normal structures are not re-flexly injured. The lightest touch, a tourniquetand the finest instruments are essential forthis work. Sharp dissection with sharp in-struments and the handling of tissues with

fine hooks instead of forceps will minimize re-action and encourage scar-free healing.A bloodless field is essential for accurate

surgery and a pneumatic tourniquet can beleft in position for an hour with safety. Ifon removal of the pressure cuff, the operationarea is compressed and the arm elevated fortwo or three minutes most of the capillaryoozing will have ceased and the remainingbleeding points can be tied with a 6/o catgut.Absolute haemostasis should be the ruie asbleeding will persist in places unsupported bythe dressing such as the thenar space andinterdigital webs. Deep haematomata causeconsiderable disturbance and lead to massivefibrosis.Most surgical procedures on the hand should

be followed by a carefully applied pressuredressing. Wool should be packed in againstall the skin surfaces and built up until it canbe evenly compressed by an elastic bandage sothat all parts are supported, oedema is pre-vented and the circulation sustained. Forty-eight hours elevation aids venous and lym-phatic drainage, minimizes post-operative dis-comfort and swelling and allows an earlyreturn of function.

The Pathology of InjuryCutting injuriesApart from acute infections, hand injuries

are caused by cutting, crushing and burning.It is important always to consider thedifferences between a ' crush' and a ' cut.'A laceration made by a sharp knife or a razordamages the minimum number of cells com-patible with the size of the injury. Immediatedrainage on to the wound surface is automatic-ally provided for the damaged tissues, andintra vascular clotting remains localized to thecapillaries surrounding the wound. The re-action to injury then tends to involve onlythe cell strata of which the wound is formed solong as infection does not supervene.

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Crushing injuriesAn injury caused by a blunt cutting instru-

ment will not only lacerate but, by virtue ofthe superadded crushing effect, will damagemany more cells in strata further away fromthe wound surface. These crushed tissueshave no drainage to the surface and oedemaresults. Whether by reflex mechanism'or bytoxic absorption, a state of increased capillarypermeability supervenes in the limb, thewidespread oedema still further impedingdrainage through the veins and lymphatics.Intra-vascular clotting starts distally and theblood supply if still further diminished mayresult in avascular necrosis of the superficiallayers of the wound. Here is an excellentpabulum in which infection can flourish.The pure ' crush ' injury, although it may

not lacerate or fracture, can, by causing severemetabolic disturbances, result in total dis-ability-the frozen hand. The oedematous re-action far from being obviously confined to thesub-cutaneous planes, invades the musculature,the deep spaces, the tendon sheaths and thejoints. If it is not energetically treated fromthe outset, much of the fluid becomes fibrinizedand later cicatrises. Muscle, tendon and cap-sular tissues subjected to high tensions and toanoxia degenerate, and the motor functions ofthe hand suffer. Digital nerves and their com-plex sensory ends are strangled in the scar, andsensory and atrophic disturbances are thesequel.

In any acute injury, it is valuable to assessthe ratio of the ' crush ' to the ' cut.' Not onlyin industrial injuries does it lead to much in-teresting information about the work ourpatients do, but in all injuries it enables usmore accurately to hazard the risk of infectionand it points the way to the correct treatment.

Burning injuriesInjuries by burning can be considered as

thermal, electrical and chemical. The thermalburn evokes a very similar reaction to thatcaused by a crush injury. There is muchvariation in effect depending upon the tem-perature and the length of exposure. Here theskin is first destroyed and, for purposes oftreatment, it is convenient to divide burns intotwo groups-partial thickness skin loss andtotal thickness skin loss. The first group com-prise degrees i and 2 in the Dupuytren's

classification, and the second group degrees3 to 6. A noteworthy point in the pathology ofburns is that there is always more tissue loss.than that occasioned by the heat itself. Thistakes the form of spreading cell necrosis dueto added infection, progressive intra-vascularcoagulation and degeneration due to oedemaand raised tissue tension. This sequence withits crippling effects can, to a large degree,'becontrolled if rational treatment is instituted atthe outset. These are the factors which makethe diagnosis of depth of all but the severestburns difficult if not impossible during thefirst few days.' The best indication is gainedfrom a study of the causation of the burn ratherthan a clinical examination of the wound.

Electrical burnsElectrical burns are caused mainly by the

heat generated in the tissues due to their re-sistance to the passage of the current. Twofeatures are worthy of mention, first that theburnt area is well demarcated, and second thatthe necrosed tissues are dehydrated by thepassage of the current. These facts suggestimmediate and active surgical treatment andexcision and replacement can give results un-obtainable by any other method of treatment.

Chemical burnsChemical burns provide the greatest puzzle

in diagnosis of depth. Much depends upon thestrength of the caustic and upon the amount ofsweat and dirt on the skin itself and, of course,upon the skin thickness at the site of injury.Generally speaking, pure Lysol and the con-centrated strong acids and alkalis will destroythe full skin thickness of the forearm or thedorsum of the hand in from IO to 20 seconds,but will take up to a minute to produce asimilar injury of the palmar skin of a work-man. These burns remain demarcated unlessthe contact period is long, or they are followedby infection.

The Immediate Treatment of HandInjuries

Crush injuriesThese injuries are common and are caused

by a wide variety of accidents. In industry,presses and mills are the worst offendersapart from the everyday occurrence of a

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BARRON: Skin of the Hand

heavy weight dropping on the hand. In thehome, serious disabilities may be caused bythe slamming of a door, and in this case thefingers are usually involved. ' Crush' injuriesare either closed or open. The skin may splitin a plane at right angles to the crushing forceand the soft tissues may be extruded thence tothe exterior. There may or may not beassociated fractures. Pain is severe and pro-longed and is due to the trauma to the sensorynerve ends. Oedema is soon apparent andmay involve the whole hand. The skin in theareas subjected to the greatest force usuallyshows evidence of bruising and ecchymosiswhilst necrosis and sloughing may occur.

TreatmentUnless there are special indications for the

treatment of fractures, the hand should be putup in the position of function. A few degreesof dorsi flexion at the wrist, all finger joints inabout 450 of flexion, the angles increasing alittle in succeeding fingers from the index tothe fifth. The thumb in palmar abductionand opposition. In this position a firmpressure dressing is applied, and the handslung to a point overhead by a loop of bandageor strapping. Severe cases, particularly wherethere are associated fractures, should be chilledwith ice bags and the temperature kept between600 and 650 F. This is an efficient anodyneand prevents congestion and oedema. Anycase where there are gaping lacerations whichcannot be sutured owing to tension should beskin grafted and the graft removed later if theskin is redundant. This prevents a granulatingsurface from forming, encourages early move-ments, and decreases the risk of infection.

The crushed finger tipCases of this sort requiring treatment usually

present in addition a nail injury or a fracturedterminal phalanx. The basic treatment isagain the pressure dressing, but the nail orphalanx may need attention. The subungualhaematoma should be drained by a drill holethrough the nail and unless this is done,necrosis of the nail bed and the phalanx can beexpected if the tension is high. If the nail bedis split the nail should be sutured into normalposition to prevent a cleft or other irregularitiesfrom forming and the drill hole should still bemade. If there is partial avulsion of the nail

bed from the bone the following techniqueshould be adopted. A small mould is made inStent wax or plaster of the nail of the samefinger on the opposite hand. This is made inthe form of a thin plaque, curved to fit the nailexactly. It is then applied to the injured nailand accurately held in position by a pressuredressing. Many gross deformities can be thusprevented. Fracture dislocations of the distalinterphalangeal joints should be put up intraction, preferably on a Bohler's splint.Lacerations without skin lossUnder good conditions of treatment, all

wounds of the hand which can be exploredunder direct vision, should be closed. Inpractice, the main exception to this rule is theperforating injury of the palm or fingers. Whenthe hand has been pierced by a bullet or asharp instrument, it is impracticable to exploreall the interstices of the wound and in attempt-ing to do so potential pathways for dissemina-tion of infection are opened up. Skin and sub-cutaneous tissue edges should be excised andthe wound lightly packed. If desired, a fine35 gauge stainless steel wire suture can beplaced across the wound and tied a few dayAlater if infection is not present. These casesshould receive prophylactic penicillin ad-ministration. If a ' crush' element is presentin these injuries and this may be marked ifbone is involved, pressure dressing, elevationand cooling should be included in the treat-ment. An accurate diagnosis as to tendon andnerve function should be made at the outset asthe picture may later be complicated byswelling and fibrosis.

All other lacerations should be subjected todebridment under local, regional or generalanaesthesia and a tourniquet. The extent oftissue removal depends upon the ratio of'crush' and 'cut' in the causation of theinjury, wider excision of the wound surfacebeing necessary when the 'crush' element ispredominant. In deep wounds this is mosteasily done under a slow-flowing stream ofsaline in which ragged and torn material mayeasily be identified. By this method it is alsopossible to make a more accurate differentia-tion between damaged and viable. tissue onthe woond surface itself.With the volar skin of the manual labourer,

it is wise to shave off the cornified skin layer

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for I in. around the w.ound margin. This layeris non-elastic and difficult to suture. It invertsthe deeper skin layers and in any case separatesafter the stitches have been removed, resultingin slow and imperfect healing. This point isworth noting also when making incisions forthe drainage of acute infections and woundsso treated heal with noticeable rapidity.Debridment having been completed andhaemostasis secured, the wound should besutured. Subcutaneous tissue should be closedwith 6/o catgut only if it tends to retract andleave a dead space. Skin sutures should beaccurate, and exact apposition of the flexioncreases should be made as stitching proceeds.Lacerations crossing the flexion creases on thevolar aspects of the fingers should be brokenup by the method of Z plasty in order to avoidflexion contractures which are otherwise verylikely to occur.The method of Z plasty as applied here is

as follows:-If AB represents the wound crossing a

flexion crease CD at 0, take a point E onAB I cm. distal to 0 and a point F i cm.proximal to 0. At E construct an angleOEX of 450, X being a point on this line inthe same sagittal plane as F. Construct asimilar angle at F prolonging the line to Y,a point in the same sagittal plane as E. Thelines EX and FY are marked on the skinand incised with .a knife. Two flaps arethen formed-FEX and EFY on bases FXand EY respectively. These flaps are under-mined in the subcutaneous plane back totheir bases, and are transposed so that pointE lies on point Y, and point F on point X.Fine sutures are placed round the flaps andclosure takes the form' shown in Fig. 5.The following stitch will be found usefulfor the corner of each flap. The needle takesthe skin just to the deep layer in the dermisin the recipient angle, passes through thecorner of the flap at the same level andagain through the recipient skin. When thestitch is tied, the flap advances and liesaccurately in position.The effect of the Z transposition is to

lengthen the suture line between A and B sothat contracture does not tend to approximatethese two points and so flexion deformity at thecrease does not take place.

Lacerations with skin lossConservative treatment of skin losses of the

hand is a potent cause of dysfunction. In thetime taken by all but the smallest of thesewounds to heal, fibrous tissue forms, contractsand shortens, distorting the hand and inter-fering with its mechanical and sensory func-tions. The prolonged healing period and theloss of dexterity and power owing to disuse,constitute an important economic problem inconnection with employment. Too many man-hours are wasted waiting for conservativetreatment to produce second-rate results.Healing will eventually take place after muchdelay with a poor type of epithelium un-buffered by normal dermis, contracted, pain-ful, disfiguring and disabling.

In general, untreated volar skin losses pro-duce flexion deformities of the wrist andfingers. Skin losses on the dorsum of the handinterfere with flexion at the metacarpophalan-geal joints and draw the thumb into adduction.Skin losses on the backs of the fingers pro-duce extension or hyperextension deformitiesat the interphalangeal joints. Persistent irrita-tion'from infection together with the contrac-tion of the wound causes oedema. Even whenhealed, the presence of the scar not infre-quently causes sympathetic vascular dis-turbances with atrophic changes in digits dueto arterial spasm and capillary paralysis. Theeffects of this syndrome may be widespread inthe hand and the changes may cause permanentcrippling. It can be seen then that there arestrong indications for the active surgicaltreatment of skin loss and this consists of theearly replacement of the skin defect.

Principles of Skin RepairIt is an axiom of reconstructive surgery that

lost tissues should be replaced by similartissues and the more this is adhered to the moresuccessful will be the repair. It is often im-possible to observe this rule strictly but if itis borne in mind the design of the repair willbe on sound lines and the outcome assured.There is, therefore, a primary necessity ofmaking a studied diagnosis of the tissue lossand a' careful evaluation of the part played byeach of the missing structures.

Subcutaneous tissueThus on the volar surface of the fingers the

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October I947 BARRON: Skin of the Hand 457

FIG. T.-Fine instruments used inhand dissection..

FIG. 2.-Pressure dressing of wool, crepe bandage and strapping.

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458 POST GRADUATE MEDICAL JOURNAL October 1947

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......:.. ,::.!.:.:::.:%;.;::;.. ....::.: :::: !:..'..:::...:!:.::::,:.::,:,:,.........:..:.::.:.:,::i.'..-'i.., -.:":.:.:...ii-.'..:,i::: i...i"--i::.::.: .:::.:.:..:..:::; .: ::.:".: ......:.:.:i:-;5:1.. -:, :!- .: :.:..:.:..: ::::: ::;.!: :....:....:.. :..... ::.::::.:::.... ::: :.::::.., .:.!:.;::::-:. ": ... ":.:: .:.-..-.. .".,... -. ... :...... .,. .. .: .........-......,..-,.---.. .: :: ::

...... .ill'."'..,.".'. ...:. .:..:...;:"2.,:....:.----.:-.: ...:..,..:...:,,j.. .::::;:::....::::::..: :.:. ,..,.u. .:.:.::.:..:.:.:,:.:.,..... ::.::.. :-,.'..:..:.

:: ::: .': :.. ...!:::....: ..:.::;..::.:::..: ::..:: ':' :..::::::.`.:':.%.: .......-.%::..::..:........ '.': .;:,:!::::::.: .....:.:....:.... ..:..:... ....:.. .:::.... ::.":,::4 .:..... ': :.....: .......:.,:..:..:::, ....: .:.:.::..................... ....; ..:

... ..

,:.:... .!.. ...........,..,. .:..: :-,:::.:: ::: ': ... ........ ........

-:.,::: .:.:.... .:.:. .:.:.:... :::;.:: :-.::-,.".: ..::,.":.:.: 1.1..:. ::; ':.::..:.-:-..:.::............... ..:.::....:.: :-:---.:.. .::! ...........:::..............:..... ....:..:.: .-::.... :...:,.: ::":,..::,. :,.;:

::.: .,:.:.: .::,-, -'--!- ....::....

-. ..::...,..,..,., ,..,.,..

:;J:- :m. ...: ...... ..:...-.%-.-.-....::.: .....::. .... .,.. .:..:.,.... !.:, :.,. ...:..-. .::;:.....:..... ::.;. :..::.:::,:,.:.:.,:..:::::::... ..; ...:. ::: .:...:....:.......... :..:::,. .:.,;:":;::'::?.... .': .,. :!;:.%-:. ... "::..:. ."..:...:.".: :.:: :.....: .:!:% :..:.... .:.,

.%-....!.... :.. :.:..c..:....... :%:::...:.% .... ...-.."...:...::.!.....,.-."..,-.,.i-:.i ..D---i ..:..... ..........i. .... ...::.::.".:..'

:.-'..:. .. .;......... :::::.::

...::..%.:...... ---:::-:-::-:-: -.:::..':'. .:..:......:.%,. ...'....:.:..:.:.:..... .... .:., ::.:.:.:...:. ..:.:. ..:,:"...,. .:.".".i. ;.:

:,::.:%.- .:,:. .:.::,:.::: .... .:::::.:::. .:..:.:.:.:.-. ",:: .:!....:..",:,:. :; .... :!.., .....:..:.%.:...

.:-..::.%...: ........:.:

,:":::: .:.:.: ::-.-: ;:,:.:...:...,.:.".,:.:.,.!.i:..4.,,:-.:-:.:..... ': :. .".: :":,::-.':- ..i...?...",.i....e,..li.....'.'... ::,.,:":: ....:. ........:.:.:. .:.,:.: .:.:... :,:,:,: .::--::",.:, -.:.::.,..,:....:.!!..!..:j!..;.;,.,.i. .:

:::.:..-.,: ::: !:.:!,;:. :::.::.:::.:,.: .%;

., ..:: .:-..::%.. ........; ... :.

FIG. 4.-The position of function.FIG. 4.-The position of function.

FIG. 3.-The frozen hand resulting from a crush injury.FIG. 3.-The frozen hand resulting from a crush injury.

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October i947 BARRON: Skin of the Hand 459

A A

a y E.y

;~- Q --

on :BFIG. 5.- The Z plastic transposition of flaps.

e t W'.FIG. 6.-The Rotation Flap,

-1I ,**sr£rg~~~~.5--=-{--- -bt F- -- 57

- ' 9 J

,t:--=------ ==4,

K--=----;\(

FIG. 7.- The Transposed Flap.

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460 POST GRADUATE MEDICAL JOURNAL October I947

.~ -

.....

oii~

FIG. 8.-Strip grafts, spot grafts and patcli grafts.FIG. iO.-Thigh flap for the repair of a palmar defect in

the region of the second and third webs.

FIG. 9.-Showing method of immobilizing a cross armflap.

FIG. i i.-Thigh flap inset into hand.

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October I947 BARRON: Skin of the Hand 46i

......

amgg

,,,.. F

.........

0'4.-- .+|- - .72I-4+I++.+~+++ -

| - +.+*A

...:-*w.FIG. I2.-Abdominal flap repair for electrical burn of the ulnar border of the wrist and hand. The burn.

FIG. 13.-The abdominal flap attached to the hand.FiG. i I.-The inset completed.

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----,- . -A-- .....

Rl- R; SX,I e&,X,E,~~~~~~~~~~~~..O ...

#;S 2 | i |~~~~~

., ......................... ;. ..... ..:. e| | |9 8 Sc~~.e:

..:

............,: :~~~~... .. : ......:...............

FIG. I6.-Inset of the pedicle completed.

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subcutaneous tissue plays a dual role. It actsas a cushion for the skin protecting it fromtrauma, and also guards the tendon and itssheath and the nerves and vessels against in-jury and subtraumatic stimuli which arie con-stantly being applied to this surface.On the dorsum of the fingers, the function

of subcutaneous fat is of much less im-portance; apart from its minor protective role,it conveys the venous plexus up to the hand.Here on the hand, the fat layer, although

normally -thin, allows the free skin movementessential to flexion and extension of the fingers.This movement is nearly 3 in. at the knucklesbetween the extreme3 of the range at thejoints. It also allows unfettered movements ofthe extensor tendons and provides a mediumthrough which the venous and lymphaticvessels course.On the palm it is the great shock absorber.

Intimately connected with the palmar fascia, itis movable and accommodating in flexion buttightly stretched in extension and is thus welladapted to the various functions of the hand.DermisThrough the dermis, the epidermis re-

ceives its nutrition and in it are found many ofthe sensory organs and nerve plexuses. Thenormal metabolism and stability of the skindepend upon an intact dermis and the in-stability of scars is often due to its absence orto defects in its structure.On the volar surface of the hand and fingers

where, owing to constant abrasion, the wastage-rate of epithelium is high, these functions ofthe dermis are of great importance. On thedorsum of the fingers, however, satisfactoryfunction of the skin is possible in the partialabsence of the dermis and on the dorsum ofthe hand, this is also true provided the sub-.cutaneous layer is intact.

From these considerations, we can examinethe indications for replacement after injury.On the volar surface of the fingers a full

thickness skin and subcutaneous tissue lossshould be replaced in all its three layers. Inthe palm, the central area between the thenarand hypothenar muscle groups again demandsreplacement of all three layers. IA free skingraft over the muscles will, itself, be satis-factory because of the good blood supply andsuppleness of the base.

On the dorsum of the fin,gers neither., thesubcutaneous tissue nor the whole thickness ofthe dermis need be replaced; and a split skingraft'proves perfectly. adequate. in.all 'ccase.On the dorsum of the hand,provided therp,isa subcutaneous tissue, covering over the-ten-dons, a split skin graft will again be satisfactQ.It is possible to do tendon surgery,later throuqghthis split skin graft if it is really thick.(J;.,.,to7 skin thickness) and if the primary 'tak,.'has been good.When the dorsum of the hand has bsp

denuded of its fatty layer, as well, all threelayers should be replaced if free finger move-ment is to be expected.

Methods of Repair of Tissue Lossi. Direct sutureThis method is applicable only to the

smallest of wounds and on the volar surfaceof the hand -and fingers there is very littleexcess of skin available for the repair. Underno conditions should tension suturing be re-sorted to as the inevitable damage to the skinedges and the subsequent widening of thescar will reproduce the condition that thewound suture was designed to prevent. Onthe dorsum there is greater laxity of tissue,and by undermining the skin in the sub-cutaneous plane certain small defects may beclosed. Transverse tension across the dorsumovef the knuckles should be avoided as thefull width of skin is required here for freeflexion at the metacarpophalangeal joints.

2. Local skin flapsThere is a limited application for these

methods and two are in common usage forsmall skin losses.

(a) Rotationflap. Tlbe rotation flap is usefulfor closure of triangular defects provided theflap incision does not cross flexion creases atright angles and so encourage secondary con-tractures. The main indication is for defectsin the distal palm, the thenar eminence, or onthe dorsum in the knuckle region. All rota-tion flaps on the hand should be based proxi-mally so as to ensure venous drainage. Con--gestion and thrombosis are the penalties fordistally placed flaps. The rotation flap is cutby extending the short side of the triangulardefect by an incision which sweeps round the

E

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arc of the largest possible circle compatiblewith the presenting surface, and ideally shouldterninate at a point on the projection of a linedrawn through the long axis of the triangle.The extension of the incision to this point isnot always possible as the base of the flap isthereby narrowed under the blood supply andthe skin is impoverished. In practice then theincision is lengthened until the flap, whenundermined, will close the defect without ten-sion. When properly designed, this flapshould leave no secondary defect requiringclosure by a free graft.

(b) Transposed flap. The principle of thismethod is to transpose the defect from one siteto another where it can be suitably closed by askin graft. Thus defects in the central palmcan be transposed to the ulnar border of thehand where a split skin or Wolfe graft' can beexpected to take and stabilize without scarringand risk of subsequent breakdown. A centralpalmar defect exposing tendons and nervescan in such a manner be closed by incisingacross the palm to the ulnar border and thenturning the incision proximally upwards to-wards the wrist. When the palmar skin isundermined the flap outlined will move acrossto close the primary defect, leaving a secondarytriangular defect over the abductor minimidigiti which is a good base for the reception ofa skin graft. This principle can be used in thetreatment of defects in the interdigital websand for small skin losses on the volar aspect ofthe fingers. In both these instances, thedefects can be transposed to the sides or backsof the fingers, in which situations skin graftsare satisfact6ry.3. Free graftsThe free skin grafts which were formerly

described as either Thiersch gra,fts or Wolfegrafts, are now subdivided into a number ofcategories. In the hand there are importantindications for adapting a particular type. ofgraft to the area grafted, and much importanceshould be attached to this if optimum resultsare to be obtained.,-The emergency surgery of hand defectsoffers great scope for the use of the free graft.-It is by far the most useful method of repairand the saving of time and disability should-recommend it to those who deal with acutehand injuries.

Skin GraftsTHICK

Wolfe Graft Full thickness .045 int to .032 in.Thick split skin

oi}. in.i02 n.

Pinch Graft .045 in. at centre.oo8 in. at periphery.

THINHalf skin thickness .020 in.

r Spot graftsOne-third split skin .oi2 in. Patch ,

Strip tThiersch Graft .oo8 in. to .oio in.

Wolfe GraftThis graft includes the whole of the dermal

and epidermal layers. It is cut either freehandor in large areas with a Padgett dermatome.Of all skin grafts it is the least ready to take andrequires every refinement of technique to en-sure successful transplantation. The commondonor sites are the abdomen and inner aspectof the upper arm. The donor site must beclosed by suture or by a split skin graft toavoid prolonged healing and unnecessaryscarring.

If cut freehand, a pattern of the defect ismarked on the donor skin and outlined with aknife, one edge is lifted with a skin hook andby careful dissection the graft is split offbetween the dermis and the subcutaneous fat.Not a vestige of fat should remain on the graftor the take will be jeopardized. The skin mustbe handled without trauma- and should bemanipulated only with the fingers or with asharp hook. The crushing effect of forcepswill cause points of necrosis in the devitalizedskin.To prevent collections of serum or blood

under the graft, it should be punctured at half-inch intervals over its whole surface with alarge, straight cutting needle pr with a fine-pointed knife. These puncture wounds healrapidly after allowing drainage from the woundin the first crucial hours after operation. Graftdrainage has an important place in the handwhere irregular surfaces are to be covered andabsolute immobility is difficult to obtain.The Wolfe graft is accurately sewn into the

edges of the defect by either interrupted finesilk sutures or by a running mattress stitch.Exact edge to edge alignment and eversion arenecessary if marginal scarring is to be reduced

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to a minimum. As with all free grafts, a firmpressure dressing and immobilizing'splint isused during the first seven to ten post-operativedays, after which time the dressing is removedand the graft inspected. Further care consistsof protective dressings, general exercises andmeasures to encourage stability of the skin.

Infection or the risk of infection is anabsolute contraindication for the use of aWolfe graft. One should hesitate to employ iton a hand injury more than six to eight hoursold, and only then after a careful debridmenthas been done, particularly if there has been acrush' element present.The principle indication for the Wolfe graft

is for the replacement of skin defects of thevolar surfaces of the fingers and thumb inwhich the subcutaneous layer is intact. Herethe full buffering effect of the dermis is im-portant and this layer should be replaced whendestroyed. Whatever the shape or size of thedefect, if it crosses a flexion crease on a digitit should be enlarged until its lateral marginsrun along the lateral axes of the finger, or atriangle of intact skin should be sacrificed withits apex at a point on, or posterior to, this line.In this way, a secondary contraction of themarginal scar can be prevented.The lateral axial line is determined by

flexing all the finger joints and viewing thedigit from the side. The posterior limits of theflexion creases are marked and when the fingeris straightened a line is drawn through thesepoints. It will be noted that this line is alittle more posterior than would at first beapparent.

In practice any'longitudinal incision anteriorto this line may, during healing, cause a flexioncontracture, so that incisions for access to thefinger should be designed accordingly.A common indication for the Wolfe graft is

for the repair of skin losses on the finger tips.An accurate diagnosis of the loss should bemade and if there has been destruction of muchof the pulp substance this must be replaced byother methods.A common tip injury is caused by a bread or

bacon slicer which removes a circular area ofskin off the terminal pulp. This defect hassloping margins, the loss being thickest in thecentre and when small may confidently be re-paired with a Pinch graft. The skin for this

graft is elevated on a needle point and whiletented upwards is sliced off cleanly with aknife. It is thin at the edges and full thicknessin the centre, and is well suited to these smalldefects.Where possible the proximal edge of tip

defects should be trimmed to run parallel withthe papillary ridges in this region then the scarwill be minimal and there will be less likelihoodof secondary pulp distortion.The Wolfe graft is also indicated for closure

of central palmar defects in the triangle boundedby the bases of the fingers and the borders ofthe thenar and hypothenar eminences. Pro-vided the subcutaneous layer is intact, thesegrafts do well and may even be satisfactoryover small exposures of palmar fascia. Raggedwounds of the palm which need grafting arebetter trimmed into a triangular shape withthe edges parallel to the various creases. Sub-sequent contraction of the marginal scars isreduced to a minimum, scars which if badlyplaced so easily cause deformities at the meta-carpophalangeal joints and transverse palmarshortening.

The Thick Split Skin GraftThis graft, although differing little in thick-

ness from the Wolfe graft, has certain differentproperties. It takes more readily on trans-plantation but the epithelium does not maturein quite the same fashion presumably owing topartial lack of dermal support. It is thus in-herently slightly less stable than its full thick-ness counterpart. This minor defect can, how-ever, be overcome by using it on an ideal base,and in the hand such an area is found on thethenar or hypothenar muscJes. When there isskin loss in either of these regions or in theulnar border of the first web which is formedby the first dorsal interosseus muscle, satis-factory and permanent function of the graft canbe expected. In any appreciable size the thicksplit skin graft can be cut only with a derma-tome, a pattern should be used and its methodof application is the same as for a full thicknessgraft.

The Thin Split Skin GraftThis is the graft used to replace the skin on

the dorsum of the hand and fingers. Normallythe dorsal skin is much thinner than that on

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the volar surface and its function is that of anelastic rather than a protective covering or anorgan of touch. Thermal stimuli are morereadily appreciated through the dorsal skin,but it lacks fine discriminatory sensibilitywhich is found on the palmar aspect of thefingers.These grafts take more easily than is the

case with thick grafts, and can even be reliedupon, if drained by multiple punctures, tosurvive in the presence of infection. Demand-ing less nutriment for survival they can bebased on relatively avascular capsular or tendontissues and are of great value in the early treat-ment of burns. The one-third thickness graftprovides an adequate permanent cover for, thedorsum of the fingers, and half thickness skinis used for the knuckle region and the dorsumof the hand. The tendency for the thinnergraft to contract after healing is compensatedfor by the pull of the long flexor tendons andby' the absence of concave surfaces on thedorsum. Provided there is a good initial takesubsequent contractures should not arise.

The Spot, Patch and Strip GraftsThe grafts previously described are used in

sheets. Each sheet covers completely an areadenuded of skin. Even for the thinnest sheetgraft, infection, with its liberation of pus andexudate from the wound surface, is a formid-able deterrent to adhesion. A relatively smallamount of exudate will balloon the graft off itsbed and the regenerative processes between thetwo become impossible. The accumulation oftoxic products macerates both the skin and thewound surface, so that by injudicious graftingthe healing time may be greatly prolonged.

Various advantages are gained by dividingthin skin up into small units, and the three incommon use are spots (the size of pin heads),patches (from W to i cm. square), and strips(i to i cm. in width and variable in length).These units are placed on the wound surfaceleaving spaces between them so that drainagecan escape into the dressings and so be con-ducted away from the deep surface of the skin.The problems of movement are not so acutewith this method as motion at a joint is notnecessarily transmitted over the whole of thegrafted skin. Further, for a given amount ofskin cut from a donor site a much larger area

can be covered which, although it has littleapplication in hand surgery, may be' of con-siderable importance in widespread bums.

In general, the heavier the infection thesmaller the graft unit used. Thus even whenthere is frank pus on a recent wound it ispossible to obtain a good take by spot grafting.Patches and strips are used ot less heavilyinfected surfaces, but in the presence of a goodblood supply remarkable results can beachieved by their use, even in the presence of afairly profuse infection.These graft units coalesce by epithelial re-

generation from their edges, thus the interven-ing areas are held by scar epithelium. Graftunits should therefore be placed close togetherleaving just a millimetre or less for drainagebetween them, and strips should be' placed inthe long axis of the dorsum of the hand, trans-versely on the volar surface of the fingers andparallel with the normal creases on the palm.This prevents the development of scars whichare at variance with the principles of surgeryof the hand, early freedom of 'movement ispossible, secondary deformities are less likelyto be troublesome. So great is the importanceof early epithelialization of hand wounds andburns, that with these methods at our disposalgrafting procedures should not be left until thedefects are sterile. Each'day that a raw surfaceis allowed to remain detracts from the finalresult.

Pedicle GraftsThese more complicated methods of repair

have a place in the immediate treatment ofhand injuries. These procedures are done intwo stages because the grafts contain skin andsubcutaneous tissue and must thus be trans-planted in vascular continuity to survive. Theimpossibility of transplanting skin and fattogether as a free graft has been mentioned,bnt there are frequent occasions for the re-placement of both these layers, and it is thenthat the pedicle method of transference fromdistance is used. Briefly, the indications forpedicle grafting are skin and subcutaneoustissue losses on the volar surface of thefingers, the central palmar triangle -and thedorsum of the hind.There are two contraindications for the use

of this method. If the wound is more than

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BARRON : Skin of the Hand

six to eight hours old and, by the nature of itscausation, infection is likely to occur, thepedicle flap should not be used. Similarly ifthe tissue loss is caused by a severe crushinginjury or is accompanied by a crush in anotherpart of the hand, the difficulty of controllingoedema and the subsequent prolonged jointstiffness rule out this method as a primary re-pair. Under these conditions it is preferableto close the defect by one of the free grafts,whichever may be indicated, regarding this asa temporary skin dressing which can be re-moved when the danger of infection andoedema is passed and proceeding then withthe pedicle flap reconstruction.'A suitably chosen free graft will overcome

the problem -of infection and a pressuredressing and elevation will control the oedema.There is some evidence to show that treat-

ment by cooling may be effective in the pre-vention of oedema if ice packs are used post-operatively. The full pressure dressing andelevation routine may be discarded and theuse of primary flap repairs may be extended tocertain crush injuries.The variations in this type of transplantation

are limitless and much depends upon the in-genuity of the operator as to the method ofchoice for a given defect. The ideal is to re-place lost tissues by similar tissues both inqualitv and in quantity. Thus it is ridiculousto replace the dorsum of a hand with anepidermal flap containing the full thickness ofthe abdominal fat, the result is functionally andcosmetically grotesque, nor is it reasonable toreplace digital skin with a bulky mobile flapwhich on compression flows aimlessly roundthe supporting phalanges. Accurate quantita-tive replacement is just as important as theproper choice of the donor site.

Examples of Pedicle FlapsThe repair of central palmar defectsThe commonly advocated abdominal flaps

are not ideally suited to this type of case. Inorder to prevent the flap from kinking in thebridge between the abdomen and the hand,the latter must be held in full supination. Thisis an unnatural position and is impossible tomaintain unless a massive plaster jacket withan arm extension is made. If pronation doesoccur the contact between palmar skin and the

abdomen encourages sweating and macerationof the skin and infection of the suture line isdifficult to prevent.The best choice lies between the opposite

forearm or the internal aspect of the thigh onthe same side as the donor site and of the two,the forearm is' usually more convenient.A suitable position for the flap is found on

the front of the forearm and is based proxim-ally. The flap is raised and the donor defectgrafted, using a 4 split skin graft. The flap issewn into the palmar defect and the two armsare immobilized together in plaster. Theposition is fairly comfortable and easy to main-tain for two weeks when severance of the flapis completed.The same technique is used for the thigh

flap but here the problems of immobilizationare much more difficult and it is better toreserve the operation for children and ado-lescents in whom such fixation is less irksome.

AbdominalflapThis flap should be restricted to the repair

of defects on the dorsum of the hand. Theposition during transfer is natural and amplematerial is available. Th-e flap can be basedabove and medially, below and laterally, or canhave a double base and thus become ' a bridgeflap.' The donor site is the lower quadrantand should be somewhat more lateral in womenowing to the excessive fatty deposition over thelower third of the rectus muscle.When an abdominal flap with a single base

is contemplated, it should be designed so thatthe base is at least equal to the length of theflap. The circulation will then be sufficient.When this rule is followed it is permissible totrim off all excess of fat and leave just enoughin the flap to replace the subcutaneous tissueloss on the hand. It is sometimes necessary toenlarge the hand defect so that a safe flap ofthis type can be used and there need be nohesitation in so doing.When there is a narrow defect crossing the

entire width of the dorsum a bridge flap canbe used and a safe ratio between length andbase in this case is 5 to 2.The donor site of the flap should be closed

by a split skin graft so that all raw areas arecovered. Failure to obtain complete closure isthe commonest cause of sepsis, delayed healing,and scar formation in the flap.

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When the flap has been sewn into the defect,the position of the hand and arm is maintainedby strapping it to the chest and abdomenwith elastoplast. With, children, however, itis safer to use plaster immobilization and forthem a light plaster jacket with a rigid armextension serves the purpose well.The second stage is done within two or

three weeks. The base of the flap is severedand set into the margin of the hand defect.This should truly be a marginal inset as in allcases at least iths of the flap should be attachedto the hand at the first operation, the designallowing for just a short bridge between theabdomen and the hand.These flaps allow successful extensor tendon

suture to be done during the first stage solong as the fingers can be splinted in full ex-tension. They also provide an excellentmedium for subsequent tendon grafting, andthe grafts can be tunnelled through the fattylayer underneath the flap.

The Tubed PedicleThis cannot be used in an emergency as a

means of importing tissue as the skin tubemust be formed on the abdomen or chest atleast three weeks before transference can be

made. In gross injuries, however, there areoccasions when a temporary skin graft shouldbe used for the hand and subsequently re-placed with skin and fat. In-these cases mUchtime and an operative stage can be saved if atthe emergency operation a tubed pedicle ismade which will be ready to transfer to thehand after the acute phase of the injury hassubsided. The planning of tubed pedicle re-pairs is fraught with difficulty, and an accurateforecast of the whole surgical programme mustbe made before the size and situation of thetube is decided upon. An error in judgment atthe first operation may jeopardize the wholeresult and it may not be apparent until severalsubsequent stages have been completed, bywhich time the mistake may well be irrevocable.

ConclusionsThe pathology and treatment of recent skin

and subcutaneous tissue injuries of the handare viewed from the angle of the plastic sur-geon. Some of the more general aspects of theburnt hand are mentioned but in view of theextensive literature already in existence, detailsare not given. The basis of early treatment ofthese injuries is the prevention of infection,oedema and granulating surfaces.

BIBLIOGRAPHYBUNNELL, S. (944), ' Surgery of the Hand,' Lippincott.ISELIN, M. (I945), 'Chirurgie de la Main,' Masson.WOOD-JONES, E. (194I), 'Principles of Anatomy as Seen in the

Hand,' Bailliere, Tindall and Qox.BROWN, J. B., and BYARS, L. T. (1940), Lancet, 6o, 503,November.

EDITORIAL (continued from page 452)

In cases of extrahepatic block, where theportal vein itself is affected, porto-venocavalanastomosis is not feasible and spleno-renalanastomosis has to be carried out. Technically,Blakemore and Whipple find the vitalliumtube technique to be of great value but a tubeof adequate calibre should be used. Failurefrom thrombosis at the site of anastomosis hasbeen uncommon; it should be noted, however,that successful anastomosis is more likely to beobtained in cases of portal hypertension than inordinary vein-to-vein anastomosis, wherefailure is common as a result of the lowpressures in the systemic veins. In portalhypertension the pressure in the portal vein is

high, and there is a considerable differencebetween the pressure in it and in the venacava. Success in these cases for this reasonshould approach the success commonly ob-tained in arterial anastomosis.

Seventeen of Blakemore's cases have beenfollowed up for more than six months andsome up.to two years. In addition to the dis-appearance of haemorrhages and ascites themajority have shown considerable gains inhealth, weight and appetite and improvementin liver function.

BIBLIOGRAPHY

Whipple, A. O., Annals of Surgery, 122, OCt., '945.Blakemore, A. H., Annals of Surgery, 122, OCt., 1944.Blakemore, A. rI., S.J.o., 84, 645, April, I944.

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THE SKIN HAND - Postgraduate Medical Journal · 453 THE SKIN OF THE HAND The Immediate Treatment of...

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