54.9 Degloving or avulsion injuries

These are extreme versions of the injury in the previous section. If a vehicle runs over a patient’s limb, it may tear large flaps of skin from the tissues under them. If his skin is hanging loose, as in A, or C, in Fig. 54-10, the diagnosis is obvious, but if it is merely separated from the tissues underneath by a haematoma, as in B, the diagnosis is not so easy. To begin with his skin may look quite normal, and only necrose later. If you are in any doubt, feel it carefully, to make sure it is attatched to the tissues underneath, and look at it again 48 hours later.

If you suture a large piece of degloved skin back in place, it will die, so manage the patient as described below.

Figure 54.9: TRIMING THE EXCESS FAT OFF A FLAP will help it to unite better. Preserve the full thickness of its base, which contains its blood vessels.

DAMAYANTI (34 years) had a motor accident in which a large part of her buttock was avulsed, as in A, Fig. 54-10. Fortunately, it had a broad base and did not necrose. She was nursed in the position shown with the flap uppermost. While she lay like this for many weeks, both her arms developed such severe contractures that she was later unable to move them. LESSONS (1) Nurse the patient in a position which will allow gravity to hold a flap in place. (2) Any limb held in an abnormal position for any length of time is liable to develop contractures. So, unless there is some very good reason for not doing so, put all immobilized limbs through their full range of movements each day.

Figure 54.10: DEGLOVING INJURIES can detach a flap completely as in E, or cause a closed injury as in B. Don’t try to reapply flaps as in F, or G. Instead, remove them and graft the raw areas 3 to 5 days later. From various sources, partly with kind permission of Peter London.

DEGLOVING INJURIES

If the patient has no skin wound, aspirate the haematoma. Or, incise it, and explore it, to see how much undermining there is, as in B, C, and D, Fig. 54-10. Turn back the skin flaps, and excise or replace them as described below.

If the patient has an open skin wound, excise any grossly damaged skin.

If a flap has a base which is broader than its length, preserve it, trim the fat underneath it as in Fig. 54-9, and reapply it immediately as in E, Fig. 54-10.

If a piece of skin is free, or has a base which is too narrow to let it survive as a flap, excise all the degloved skin and fat and manage the patient’s raw wound as described below.

If raw surfaces remain uncovered, take split skin grafts (57.5). Apply them immediately, if the base is favourable (as with muscle). If it is unfavourable, take the grafts, store them (57.8), and cover the wound with dry dressings. At 3 to 5 days when granulations are forming, remove the dressings, and any dead tissue, and apply the stored graft.

CAUTION! (1) If there is a tyre mark on the patient’s skin, he will certainly have a degloving injury under it. (2) Never replace any flap of skin which is longer than its base.