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Classification of soft-tissue degloving in limb trauma
Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, 1865e1869
Classification of soft-tissue degloving in limb trauma Z.M. Arnez a,d, U. Khan b,*, M.P.H. Tyler c a
Ospedali Di Cattanara, Strada di Fiume, 447-34149, Trieste, Italy Department of Plastic Surgery, Frenchay Hospital, Frenchay Park Road, Bristol BS8 1SY, UK c Department of Plastic Surgery, Stoke Mandeville Hospital, Aylesbury, Buckinghamshire, UK d Department of Plastic Surgery and Burns, Medical Centre, Zaloska Cesta, Ljubljana, Slovenia b
Received 29 April 2009; accepted 14 November 2009
KEYWORDS Limb; Degloving; Injury; Pattern
Summary Compressive, tortional and abrasive deforming forces are translated to the limbs during high energy trauma. The long bones may be fractured in many patterns with a varying extent of fragmentation and comminution but the soft-tissues appear to absorb the forces in a predictable way. We retrospectively reviewed a series of 79 complex limb injuries treated in a dedicated centre where the clinical notes and photo-documentation were meticulously kept and where the outcomes were known. The soft-tissue injuries were then described and revealed four patterns of injury: abrasion/avulsion, non-circumferential degloving, circumferential single plane and circumferential multi-plane degloving. These patterns occurred either in isolation or occasionally in combination. Resuturing of degloved skin was only successful in non-circumferential (pattern 2) cases. Radical excision of devitalised tissue followed by soft-tissue reconstruction in a single procedure was successful in all patterns apart from pattern 4 (circumferential multi-plane degloving). In pattern 4 we recommend serial wound excision prior to reconstruction. ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Severe, complex limb trauma remains a challenge.1,2 The principles of management when there is an open fracture are becoming clear.2,3 Comprehensive excision of de-vitalised hard and soft-tissue followed by appropriate skeletal fixation and vascularised soft-tissue cover is the cornerstone of modern care.2,3 Degloving has been defined as avulsion of the skin off the underlying muscle and bone.4 However, when the soft-tissue envelope has been degloved the assessment of * Corresponding author. Department of Plastic Surgery, Frenchay Hospital, Frenchay Park Road, Bristol BS8 1SY, UK. Tel.:þ44 1179 701212. E-mail address: [email protected] (U. Khan).
these tissues may be unclear. This makes the decisions of what to excise and what to conserve a difficult one. Direct visual inspection of the degloved skin is a weak predictor of the extent of injury.5 Use of intra-venous flouroscein has been proposed as a better method but may over-estimate the line of demarcation between viable and non-viable skin.6 The use of thrombosed sub-cutaneous veins have been proposed by Waikakul to mark the zone of demarcation.7 In another series it was proposed that ‘test shaves’ of the degloved skin may show this demarcation with brisk pink bleeding from viable tissue.8 Thus there are surrogate indicators of skin/fat vitality. There have also been publications describing novel ways to use the devitalised, degloved skin.9,10 Some have
1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.11.029
1866
Z.M. Arnez et al.
advocated the use of a dermal equivalent in purely degloved skin without an open fracture.11 Degloving injuries have also not escaped the attention of surgeons advocating negative pressure dressing.12 What has hitherto not been made clear is whether categorisation of degloved integument can provide a means of prognosis when assessing the injury as a whole. This series of 79 cases which were treated in a specialist centre with direct involvement of the senior author (ZMA) were used to try and investigate this dimension in complex limb trauma.
Materials and methods To describe the patterns of soft-tissue injury we retrospectively reviewed a total of 68 patients with a total of 79 injured limbs. The mean age was 29.5 (range 3e84) with 53 males and 15 females. Fifty one (65%) were of the lower limb. Injuries with the following criteria were included: 1) all patients with a skin lesion greater than 5 cm with circumscribed degloving (ie a soft-tissue injury greater than IO/IC 3 on the AO/ASIF classification)13 2) adequate photo-documentation of the initial injury to allow accurate classification prior to reconstruction. 3) injuries proximal to the metacarpals and metatarsals The causes of the injury were: road traffic accidents in 45%; pedestrian hit by vehicle 24% and machinery/farm accidents 31%. Two limbs went onto amputation. There were 40 long bone fractures (24 tibial; 6 femoral and 10 in the upper limb). The notes, X-rays and a total of 2043 slides (an average of 26 slides per injury) were reviewed.
Outcome measures
Figure 1 (a) This shows a typical pattern 1 lesion with an abrasion/avulsion of the integument. This also demonstrates how tissue loss occurs when the limb is dragged along an abrasive surface with force. Free tissue transfer is often mandatory for limb salvage in this pattern as was the case here (b).
Pattern 2- Non circumferential degloving In this pattern the majority of skin is still present either as a flap or as an area of extensive undermining. The plane of avulsions is, in the main, confined to a single layer (usually between the deep fascia and the subcutaneous fat and skin (Figure 2)).
Pattern 3- Circumferential single plane degloving Either open or closed circumferential degloving of the integument confined to a single plane (usually between the deep fascia and the subcutaneous fat and skin e Figure 3).
The management of all cases was radical wound excision and immediate wound cover as described elsewhere.14 Flap coverage was in 66% cases the rest underwent skin grafting. A healed wound was defined as one which was free of any dressings. Whether the wound healed by primary healing defined as a healed wound within two weeks of reconstruction or by secondary healing Defined as a healed wound after two weeks of reconstruction was used as an outcome measure of our surgical strategy. The rate of primary healing was statistically compared for the four patterns using a chisquared analysis.
Results During the study it became clear that the softtissue injury fell into distinct patterns as follows:
Pattern 1- Limited degloving with abrasion/avulsion There is loss of tissue as a result of the abrasive force. There is little undermining of the remaining skin edges. Since the majority of these cases occurred over bony prominences (such as the malleoli) there is exposed bone/ joints (Figure 1).
Figure 2 This shows a typical pattern 2 degloving (a) degloving lesion with a single plane non circumferential degloving pattern. Following excision the wound was resurfaced with split skin grafts (b).
Classification of soft-tissue degloving in limb trauma
1867
Pattern 4- Circumferential multiplane degloving
Figure 3 In this case a circumferential single plane degloving was washed out, re-sutured and drained (a). As can be seen this was unsuccessful with full-thickness necrosis declaring several days after such surgery. Note that the original assessment was by experienced surgeons indicating the malign nature of these lesions. Limb salvage was by way of free tissue transfer (b).
In addition to pattern 3 there is also a breach of muscle groups and even between muscle and periosteum (Figure 4). Clearly this pattern indicates a higher degree of energy transfer to the limb. Table 1 shows the healing outcomes (primary or secondary) for the four patterns. The results demonstrate that when the degloving is circumferential (pattern 3 and 4) then regardless of the methods used to resurface the wound (flap and or graft) primary healing was not achieved in the entire wound. A chi-square test was undertaken comparing the primary healing rates of the four patterns. This confirmed that this observed difference between patterns 1&2 and 3&4 was statistically significant (p < 0.01). Table 2 shows the healing according to pattern and type of reconstruction. Fourteen injuries underwent simple resuturing of the skin. Only one (pattern 2) achieved primary healing. There were 9 purely circumferential degloving injuries (eight pattern 3 and one pattern 4) which were sutured. All developed full-thickness necrosis and required alternative methods of soft-tissue reconstruction. The rate of primary healing of those cases which required flap coverage is shown in Table 3. This figure shows that the rate of primary healing is much lower in patterns 3 and 4 even when flap transfer is used as a method of immediate cover.
Discussion Degloved limb skin post-trauma has been managed by many different surgical strategies. MacCollum recommended conservative management in his series of 26 ‘wringer’
Figure 4 The most severe form of degloving in our opinion. Here the deforming forces are so great that the deep fascia is breached and trauma is sustained by the underlying muscle groups (multiplanar degloving) (a). In these cases we urge caution during surgical management. The patient must be prepared for serial returns to theatre prior to definitive reconstruction as happened in this case (b).
1868
Z.M. Arnez et al.
Table 1 This illustrates the analysis of the measured outcome (primary versus secondary healing rates) of the four patterns of degloving described. Note how the primary healing rate decreases for patterns 3 and 4. The numerical value is the actual number of cases. Pattern 1 Pattern 2 Pattern 3 Pattern 4 Total Primary 22 healing Secondary 6 healing
14
6
5
47
1
11
14
32
Total
15
17
19
79
28
injuries.4 Conservative management is where sub-cutaneous haematoma and dead fat is removed followed by drainage and pressure dressings. MacCollum noted the development of delayed necrosis and warned of the dangers of subsequent infection. Hudson et al treated 16 closed degloving (non circumferential) injuries in a prospective study with this technique.15 They reported only one case which required skin grafting. A concern with conservative management of large injuries is that injured muscle is not directly inspected. This may hide an evolving compartment or crush syndrome. The majority of the literature recommends surgical excision with much discussion centred on the assessment of the skin vascularity and subsequent debridement. The avulsed skin has been used a source of skin grafts (split or full thickness).9,10 Some have advocated combining the de-fatting of the avulsed skin with fenestration followed by negative pressure dressing.12 A second option when there is significant degloving is to commit the patient to serial excisions prior to reconstruction. A theoretical disadvantage of this technique is the potential for bone desiccation and nosocomial infection.16 In our cases serial excisions were not planned since the injuries were treated by radical excision of non-viable skin/muscle (as adjudged by expert clinical assessment) followed by immediate soft-tissue reconstruction.14 This technique is open to criticism, negative pressure dressings were not used and the radical nature of excision may have removed healthy tissue.
However, the fact that ultimately there were only two cases of amputation implies a robustness of our protocol. This series however, is weakened by the fact that upper and lower limb injuries were analysed as well as the fact that children as well as adults were not differentiated. Despite these shortcomings this is a large series of patients who were treated in an identical manner. We are self critical of this method of treatment particularly in pattern 4 and some cases of pattern 3. Thus using primary healing as an outcome measure instead of delayed amputation suggests that our radical approach needs to be adjusted when managing cases with pattern 3 and 4. From the analysis of this series of patients and based on our proposed categorisation into the four basic patterns we suggest the following protocols in an effort to improve the rate of primary healing with the understanding that patterns may co-exist in the same limb: 1- Limited degloving with abrasion/avulsion injuries. Free tissue transfer is needed as underlying tendon/bone/ joints are exposed. Tissue excision is minimal (wound circumcision). All of these cases required free-tissue transfer. Flap reconstruction lead to prompt primary healing. 2- Non circumferential degloving injuries. These injuries need careful assessment of the vascularity if a conservative approach is to be employed. Tissue excision is almost always needed but when either skin grafts or flap reconstruction is used the wound heals by primary intention. 3- Circumferential single plane degloving. The presence of circumferential degloving is associated with delayed (secondary) healing. Circumferential degloving is a contraindication to re-suturing. The majority of these flaps are excised in their entirety. Underlying muscle is assessed for viability and only when this can be assured is the wound reconstructed. When it cannot be assured a return to theatre is planned for a further assessment. 4- Circumferential multiplane degloving. Patients sustaining these injuries had suffered the greatest degree of tissue disruption. These cases had the lowest rate of primary healing when using our original, single stage protocol. Thus we would recommend a staged reconstruction in these cases as a matter of course.
Table 2 This table is a further refinement of the data to show how the outcome changed with differing surgical treatments. The bold number is the actual number of cases treated and the numbers in italics reflects the types of healing achieved (primary versus secondary healing). Note that even with flap surgery the majority of pattern 4 cases failed to heal primarily.
Resutured
Excise and SSG
Excise and flap
Total
Pattern 1
Pattern 2
Pattern 3
Pattern 4
Total
5 1 primary 4 secondary 6 6 primary 0 secondary 17 15 primary 2 secondary
0
8 0 primary 8 secondary 1 1 primary 0 secondary 8 5 primary 3 secondary
1 0 primary 1 secondary 5 0 primary 5 secondary 13 5 primary 8 secondary
14
1 1 primary 0 secondary 14 13 primary 1 secondary
13
52
79
Classification of soft-tissue degloving in limb trauma Table 3 This table aims to illustrate a further refinement of the data in Table 2 in that the fate of those cases where a flap reconstruction was used (regardless of injury pattern) was assessed for primary healing (as a percentage of the pattern specific total number). Again the percentages drop significantly for patterns 3&4 when compared with patterns 1&2. Primary healing rates following excision and flap coverage Pattern Pattern Pattern Pattern
1 2 3 4
88% 93% 63% 39%
Conflict of interest statement There are no conflicts of interests from any of the authors with respect to the publication of this study. Ethical approval and funding was provided by the relevant committees of the Medical Centre, Zaloska Cesta, Ljubljana, Slovenia.
Funding None.
References 1. Bosse MJ, MacKenzie EJ, Kellam JF, et al. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med 2002 Dec 12;347: 1924e31.
1869 2. Naique SB, Pearse M, Nanchahal J. Management of severe open tibial fractures: the need for combined orthopaedic and plastic surgical treatment in specialist centres. J Bone Joint Surg Br 2006 Mar;88:351e7. 3. Khan U, Smitham P, Pearse M, et al. Management of severe open ankle injuries. Plast Reconstr Surg 2007 Feb;119:578e89. 4. MacCollum DW. Wringer arm. N Engl J Med 1938;218: 549e52. 5. Kudsk KA, Sheldon GF, Walton RL. Degloing injuries of the extremities and torso. J Trauma 1981;21:835e9. 6. McGrouther DA, Sully L. Degloving injuries of the limbs: long term review and management based on whole body flourescein. Br J Plast Surg 1980;33:9e24. 7. Waikakul S. Revascularization of degloving injuries of the limbs. Injury 1997;28:271e4. 8. Ziv I, Zeligowski A, Elyashuv O, et al. Immediate care of crush injuries and compartment syndrome with split-thickness skin excision. Clin Orthop Relat Res 1990;256:224e8. 9. Minten L, Hovius SE, Gilbert PM. Degloving injuries. A retrospective study at the University Hospital Rotterdam. Acta Chir Belg 1992 JuleAug;92:209e12. 10. Khan U, Ho K, Deva A. Exchanging split-skin grafts to reduce donor morbidity in limited pretibial degloving injuries. Plast Reconstr Surg 2004 Apr 15;113:1523e5. 11. Herlin C, Louhaem D, Bigorre M, et al. Use of Integra in a paediatric upper extremity degloving injury. J Hand Surg Eur Vol 2007 Apr;32:179e84. Epub 2007 Jan 16. 12. Meara JG, Guo L, Smith JD, et al. Vacuum-assisted closure in the treatment of degloving injuries. Ann Plast Surg 1999 Jun; 42:589e94. 13. Arnez ZM, Tyler MP, Khan U. Describing severe limb trauma. Br J Plast Surg 1999;52:280e5. 14. Arnez ZM. Immediate reconstruction of the lower extremitye an update. Clin Plast Surg 1991 Jul;18:449e57. 15. Hudson DA, Knottenbelt JD, Krige JEJ. Closed degloving injuries: results following conservative surgery. Plast Reconstr Surg 1992;89:853e5. 16. Park SH, Silva M, Bahk WJ, et al. Effect of repeated irrigation and debridement on fracture healing in an animal model. J Orthop Res 2002;20-6:1197e204.
Classification of soft-tissue degloving in limb trauma Z.M. Arnez a,d, U. Khan b,*, M.P.H. Tyler c a
Ospedali Di Cattanara, Strada di Fiume, 447-34149, Trieste, Italy Department of Plastic Surgery, Frenchay Hospital, Frenchay Park Road, Bristol BS8 1SY, UK c Department of Plastic Surgery, Stoke Mandeville Hospital, Aylesbury, Buckinghamshire, UK d Department of Plastic Surgery and Burns, Medical Centre, Zaloska Cesta, Ljubljana, Slovenia b
Received 29 April 2009; accepted 14 November 2009
KEYWORDS Limb; Degloving; Injury; Pattern
Summary Compressive, tortional and abrasive deforming forces are translated to the limbs during high energy trauma. The long bones may be fractured in many patterns with a varying extent of fragmentation and comminution but the soft-tissues appear to absorb the forces in a predictable way. We retrospectively reviewed a series of 79 complex limb injuries treated in a dedicated centre where the clinical notes and photo-documentation were meticulously kept and where the outcomes were known. The soft-tissue injuries were then described and revealed four patterns of injury: abrasion/avulsion, non-circumferential degloving, circumferential single plane and circumferential multi-plane degloving. These patterns occurred either in isolation or occasionally in combination. Resuturing of degloved skin was only successful in non-circumferential (pattern 2) cases. Radical excision of devitalised tissue followed by soft-tissue reconstruction in a single procedure was successful in all patterns apart from pattern 4 (circumferential multi-plane degloving). In pattern 4 we recommend serial wound excision prior to reconstruction. ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Severe, complex limb trauma remains a challenge.1,2 The principles of management when there is an open fracture are becoming clear.2,3 Comprehensive excision of de-vitalised hard and soft-tissue followed by appropriate skeletal fixation and vascularised soft-tissue cover is the cornerstone of modern care.2,3 Degloving has been defined as avulsion of the skin off the underlying muscle and bone.4 However, when the soft-tissue envelope has been degloved the assessment of * Corresponding author. Department of Plastic Surgery, Frenchay Hospital, Frenchay Park Road, Bristol BS8 1SY, UK. Tel.:þ44 1179 701212. E-mail address: [email protected] (U. Khan).
these tissues may be unclear. This makes the decisions of what to excise and what to conserve a difficult one. Direct visual inspection of the degloved skin is a weak predictor of the extent of injury.5 Use of intra-venous flouroscein has been proposed as a better method but may over-estimate the line of demarcation between viable and non-viable skin.6 The use of thrombosed sub-cutaneous veins have been proposed by Waikakul to mark the zone of demarcation.7 In another series it was proposed that ‘test shaves’ of the degloved skin may show this demarcation with brisk pink bleeding from viable tissue.8 Thus there are surrogate indicators of skin/fat vitality. There have also been publications describing novel ways to use the devitalised, degloved skin.9,10 Some have
1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.11.029
1866
Z.M. Arnez et al.
advocated the use of a dermal equivalent in purely degloved skin without an open fracture.11 Degloving injuries have also not escaped the attention of surgeons advocating negative pressure dressing.12 What has hitherto not been made clear is whether categorisation of degloved integument can provide a means of prognosis when assessing the injury as a whole. This series of 79 cases which were treated in a specialist centre with direct involvement of the senior author (ZMA) were used to try and investigate this dimension in complex limb trauma.
Materials and methods To describe the patterns of soft-tissue injury we retrospectively reviewed a total of 68 patients with a total of 79 injured limbs. The mean age was 29.5 (range 3e84) with 53 males and 15 females. Fifty one (65%) were of the lower limb. Injuries with the following criteria were included: 1) all patients with a skin lesion greater than 5 cm with circumscribed degloving (ie a soft-tissue injury greater than IO/IC 3 on the AO/ASIF classification)13 2) adequate photo-documentation of the initial injury to allow accurate classification prior to reconstruction. 3) injuries proximal to the metacarpals and metatarsals The causes of the injury were: road traffic accidents in 45%; pedestrian hit by vehicle 24% and machinery/farm accidents 31%. Two limbs went onto amputation. There were 40 long bone fractures (24 tibial; 6 femoral and 10 in the upper limb). The notes, X-rays and a total of 2043 slides (an average of 26 slides per injury) were reviewed.
Outcome measures
Figure 1 (a) This shows a typical pattern 1 lesion with an abrasion/avulsion of the integument. This also demonstrates how tissue loss occurs when the limb is dragged along an abrasive surface with force. Free tissue transfer is often mandatory for limb salvage in this pattern as was the case here (b).
Pattern 2- Non circumferential degloving In this pattern the majority of skin is still present either as a flap or as an area of extensive undermining. The plane of avulsions is, in the main, confined to a single layer (usually between the deep fascia and the subcutaneous fat and skin (Figure 2)).
Pattern 3- Circumferential single plane degloving Either open or closed circumferential degloving of the integument confined to a single plane (usually between the deep fascia and the subcutaneous fat and skin e Figure 3).
The management of all cases was radical wound excision and immediate wound cover as described elsewhere.14 Flap coverage was in 66% cases the rest underwent skin grafting. A healed wound was defined as one which was free of any dressings. Whether the wound healed by primary healing defined as a healed wound within two weeks of reconstruction or by secondary healing Defined as a healed wound after two weeks of reconstruction was used as an outcome measure of our surgical strategy. The rate of primary healing was statistically compared for the four patterns using a chisquared analysis.
Results During the study it became clear that the softtissue injury fell into distinct patterns as follows:
Pattern 1- Limited degloving with abrasion/avulsion There is loss of tissue as a result of the abrasive force. There is little undermining of the remaining skin edges. Since the majority of these cases occurred over bony prominences (such as the malleoli) there is exposed bone/ joints (Figure 1).
Figure 2 This shows a typical pattern 2 degloving (a) degloving lesion with a single plane non circumferential degloving pattern. Following excision the wound was resurfaced with split skin grafts (b).
Classification of soft-tissue degloving in limb trauma
1867
Pattern 4- Circumferential multiplane degloving
Figure 3 In this case a circumferential single plane degloving was washed out, re-sutured and drained (a). As can be seen this was unsuccessful with full-thickness necrosis declaring several days after such surgery. Note that the original assessment was by experienced surgeons indicating the malign nature of these lesions. Limb salvage was by way of free tissue transfer (b).
In addition to pattern 3 there is also a breach of muscle groups and even between muscle and periosteum (Figure 4). Clearly this pattern indicates a higher degree of energy transfer to the limb. Table 1 shows the healing outcomes (primary or secondary) for the four patterns. The results demonstrate that when the degloving is circumferential (pattern 3 and 4) then regardless of the methods used to resurface the wound (flap and or graft) primary healing was not achieved in the entire wound. A chi-square test was undertaken comparing the primary healing rates of the four patterns. This confirmed that this observed difference between patterns 1&2 and 3&4 was statistically significant (p < 0.01). Table 2 shows the healing according to pattern and type of reconstruction. Fourteen injuries underwent simple resuturing of the skin. Only one (pattern 2) achieved primary healing. There were 9 purely circumferential degloving injuries (eight pattern 3 and one pattern 4) which were sutured. All developed full-thickness necrosis and required alternative methods of soft-tissue reconstruction. The rate of primary healing of those cases which required flap coverage is shown in Table 3. This figure shows that the rate of primary healing is much lower in patterns 3 and 4 even when flap transfer is used as a method of immediate cover.
Discussion Degloved limb skin post-trauma has been managed by many different surgical strategies. MacCollum recommended conservative management in his series of 26 ‘wringer’
Figure 4 The most severe form of degloving in our opinion. Here the deforming forces are so great that the deep fascia is breached and trauma is sustained by the underlying muscle groups (multiplanar degloving) (a). In these cases we urge caution during surgical management. The patient must be prepared for serial returns to theatre prior to definitive reconstruction as happened in this case (b).
1868
Z.M. Arnez et al.
Table 1 This illustrates the analysis of the measured outcome (primary versus secondary healing rates) of the four patterns of degloving described. Note how the primary healing rate decreases for patterns 3 and 4. The numerical value is the actual number of cases. Pattern 1 Pattern 2 Pattern 3 Pattern 4 Total Primary 22 healing Secondary 6 healing
14
6
5
47
1
11
14
32
Total
15
17
19
79
28
injuries.4 Conservative management is where sub-cutaneous haematoma and dead fat is removed followed by drainage and pressure dressings. MacCollum noted the development of delayed necrosis and warned of the dangers of subsequent infection. Hudson et al treated 16 closed degloving (non circumferential) injuries in a prospective study with this technique.15 They reported only one case which required skin grafting. A concern with conservative management of large injuries is that injured muscle is not directly inspected. This may hide an evolving compartment or crush syndrome. The majority of the literature recommends surgical excision with much discussion centred on the assessment of the skin vascularity and subsequent debridement. The avulsed skin has been used a source of skin grafts (split or full thickness).9,10 Some have advocated combining the de-fatting of the avulsed skin with fenestration followed by negative pressure dressing.12 A second option when there is significant degloving is to commit the patient to serial excisions prior to reconstruction. A theoretical disadvantage of this technique is the potential for bone desiccation and nosocomial infection.16 In our cases serial excisions were not planned since the injuries were treated by radical excision of non-viable skin/muscle (as adjudged by expert clinical assessment) followed by immediate soft-tissue reconstruction.14 This technique is open to criticism, negative pressure dressings were not used and the radical nature of excision may have removed healthy tissue.
However, the fact that ultimately there were only two cases of amputation implies a robustness of our protocol. This series however, is weakened by the fact that upper and lower limb injuries were analysed as well as the fact that children as well as adults were not differentiated. Despite these shortcomings this is a large series of patients who were treated in an identical manner. We are self critical of this method of treatment particularly in pattern 4 and some cases of pattern 3. Thus using primary healing as an outcome measure instead of delayed amputation suggests that our radical approach needs to be adjusted when managing cases with pattern 3 and 4. From the analysis of this series of patients and based on our proposed categorisation into the four basic patterns we suggest the following protocols in an effort to improve the rate of primary healing with the understanding that patterns may co-exist in the same limb: 1- Limited degloving with abrasion/avulsion injuries. Free tissue transfer is needed as underlying tendon/bone/ joints are exposed. Tissue excision is minimal (wound circumcision). All of these cases required free-tissue transfer. Flap reconstruction lead to prompt primary healing. 2- Non circumferential degloving injuries. These injuries need careful assessment of the vascularity if a conservative approach is to be employed. Tissue excision is almost always needed but when either skin grafts or flap reconstruction is used the wound heals by primary intention. 3- Circumferential single plane degloving. The presence of circumferential degloving is associated with delayed (secondary) healing. Circumferential degloving is a contraindication to re-suturing. The majority of these flaps are excised in their entirety. Underlying muscle is assessed for viability and only when this can be assured is the wound reconstructed. When it cannot be assured a return to theatre is planned for a further assessment. 4- Circumferential multiplane degloving. Patients sustaining these injuries had suffered the greatest degree of tissue disruption. These cases had the lowest rate of primary healing when using our original, single stage protocol. Thus we would recommend a staged reconstruction in these cases as a matter of course.
Table 2 This table is a further refinement of the data to show how the outcome changed with differing surgical treatments. The bold number is the actual number of cases treated and the numbers in italics reflects the types of healing achieved (primary versus secondary healing). Note that even with flap surgery the majority of pattern 4 cases failed to heal primarily.
Resutured
Excise and SSG
Excise and flap
Total
Pattern 1
Pattern 2
Pattern 3
Pattern 4
Total
5 1 primary 4 secondary 6 6 primary 0 secondary 17 15 primary 2 secondary
0
8 0 primary 8 secondary 1 1 primary 0 secondary 8 5 primary 3 secondary
1 0 primary 1 secondary 5 0 primary 5 secondary 13 5 primary 8 secondary
14
1 1 primary 0 secondary 14 13 primary 1 secondary
13
52
79
Classification of soft-tissue degloving in limb trauma Table 3 This table aims to illustrate a further refinement of the data in Table 2 in that the fate of those cases where a flap reconstruction was used (regardless of injury pattern) was assessed for primary healing (as a percentage of the pattern specific total number). Again the percentages drop significantly for patterns 3&4 when compared with patterns 1&2. Primary healing rates following excision and flap coverage Pattern Pattern Pattern Pattern
1 2 3 4
88% 93% 63% 39%
Conflict of interest statement There are no conflicts of interests from any of the authors with respect to the publication of this study. Ethical approval and funding was provided by the relevant committees of the Medical Centre, Zaloska Cesta, Ljubljana, Slovenia.
Funding None.
References 1. Bosse MJ, MacKenzie EJ, Kellam JF, et al. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med 2002 Dec 12;347: 1924e31.
1869 2. Naique SB, Pearse M, Nanchahal J. Management of severe open tibial fractures: the need for combined orthopaedic and plastic surgical treatment in specialist centres. J Bone Joint Surg Br 2006 Mar;88:351e7. 3. Khan U, Smitham P, Pearse M, et al. Management of severe open ankle injuries. Plast Reconstr Surg 2007 Feb;119:578e89. 4. MacCollum DW. Wringer arm. N Engl J Med 1938;218: 549e52. 5. Kudsk KA, Sheldon GF, Walton RL. Degloing injuries of the extremities and torso. J Trauma 1981;21:835e9. 6. McGrouther DA, Sully L. Degloving injuries of the limbs: long term review and management based on whole body flourescein. Br J Plast Surg 1980;33:9e24. 7. Waikakul S. Revascularization of degloving injuries of the limbs. Injury 1997;28:271e4. 8. Ziv I, Zeligowski A, Elyashuv O, et al. Immediate care of crush injuries and compartment syndrome with split-thickness skin excision. Clin Orthop Relat Res 1990;256:224e8. 9. Minten L, Hovius SE, Gilbert PM. Degloving injuries. A retrospective study at the University Hospital Rotterdam. Acta Chir Belg 1992 JuleAug;92:209e12. 10. Khan U, Ho K, Deva A. Exchanging split-skin grafts to reduce donor morbidity in limited pretibial degloving injuries. Plast Reconstr Surg 2004 Apr 15;113:1523e5. 11. Herlin C, Louhaem D, Bigorre M, et al. Use of Integra in a paediatric upper extremity degloving injury. J Hand Surg Eur Vol 2007 Apr;32:179e84. Epub 2007 Jan 16. 12. Meara JG, Guo L, Smith JD, et al. Vacuum-assisted closure in the treatment of degloving injuries. Ann Plast Surg 1999 Jun; 42:589e94. 13. Arnez ZM, Tyler MP, Khan U. Describing severe limb trauma. Br J Plast Surg 1999;52:280e5. 14. Arnez ZM. Immediate reconstruction of the lower extremitye an update. Clin Plast Surg 1991 Jul;18:449e57. 15. Hudson DA, Knottenbelt JD, Krige JEJ. Closed degloving injuries: results following conservative surgery. Plast Reconstr Surg 1992;89:853e5. 16. Park SH, Silva M, Bahk WJ, et al. Effect of repeated irrigation and debridement on fracture healing in an animal model. J Orthop Res 2002;20-6:1197e204.