- Email: [email protected]
Massive avulsion of skin
MASSIVE AVULSION JOHN
H.
MULHOLLAND,
OF SKIN
M.D. AND JESSE H.
MAHONEY,
M.D.
New York, New York
I
N this mechanized era injuries causing massive avuIsion of skin are not uncommon. On the other hand, such cases are rare enough so that one surgical service sees relatively few cases in comparison to their total admissions. This inexperience may be one explanation for the reIuctance with which the principles of management described by Farmer’ in 1939 have been accepted. There is a natural timidity which must be overcome in detaching avulsed Ilaps of skin from the small blood supply which remains. It has been our experience that a few avulsed skin flaps which are Ieft attached and sutured back into place will survive. A greater number, however, will develop some degree of or complete necrosis. This is particularly true where the avulsion is massive. Objections to replacing contaminated skin as a graft may be discounted if the graft is prepared properly and antibiotics are used. The manner of preparation of the graft does not violate the surgical principle of gentle handling of tissue. No ilI effects result from preparing the graft by scraping with a sharp knife. Even in the most severe injury rarely will the avulsed skin be so badly traumatized that it cannot be employed as a graft. Following are two case histories of patients with massive avulsion of skin, each treated in a different manner. CASE
REPORTS
CASE I. A fifty-one year oId white woman was admitted to the Third (N.Y.U.) SurgicaI Division of Bellevue Hospital on JuIy 5, 1949, after having been struck by a truck, injuring her right arm. Figure I shows the right arm when the patient was placed on the operating table. It may be seen that the patient had an open disIocation of the elbow. The ulna was fractured in its mid-portion but the fragments were in good position. There was aIso an open disIocation of the first and second metacarpophaIangea1 joints. At the eIbow the attachments of the tendons of the common extensors and flexors of the forearm were avulsed, the former carrying a small fragment of bone with it. The vascuIar supply to the arm and the periphera1 nerves were intact. The skin with the subcutaneous tissues was avulsed March,
I 952
from the underlying fascia from the shouIder to the heads of the metacarpaIs. There were numerous lacerations of the detached sIeeve of skin but it was
Fro. I. Case I. Shows extensive avulsion of skin and soft tissues of right arm with compound disIocation of the elbow joint and fracture of the olecranon. attached compIeteIy at the shouIder and distaIIy in the palm of the hand. As soon as the patient’s genera1 condition responded to shock therapy, she was given a genera1 anesthetic and the avuIsed skin was severed from the shouIder and from its attachment in the paIm. The entire sleeve was then split and removed. One team of surgeons proceeded to remove the fat and subcutaneous tissue from the detached skin by scraping with a sharp knife and cutting with scissors. The skin was irrigated with saIine and further bathed with a soIution of peniciIIin containing zoo units per cc. WhiIe this was being accompIished, the traumatized tissues of the arm were carefuIIy debrided by another team. The dislocations were reduced and the muscle attachments about the eIbow fixed in place with line wire sutures. An effort was made to reconstruct the capsule of the joint. A large amount of tissue from the bellies of the common extensor group of muscles of the forearm was devitalized and had to be excised. AI1 superhcia1 fatty tissue was removed from the arm. On compIetion of the debridement the skin which had been prepared was repIaced as a fuIIthickness graft covering the area from just above the insertion of the deItoid to the dorsum of the hand at the heads of the metacarpals. The arm was dressed with thin strips of vaseIine gauze over which sheet wadding was appIied with gentIe, even pressure. The arm was then immobihzed in a plaster
339
MuIhoIIand,
360
Mahoney-Massive
2
FIG.
2.
Case I. Twenty-six
AvuIsion of Skin
3 days after injury showing healing of repIaced graft.
FIG. 3. Another view of same arm.
FIGS.4 to 7. Shows function of arm and degree of healing two and a haIf years after injury. cast from the shouIder to the heads of the metacarpaIs. The cast was removed on the twentysixth postoperative day and the skin was found to be viabIe except for one smaI1 area over the Iateral condyIe which faiIed to heaL Figures 2, 3 and 4 show the patient’s condition at that time. She did very weI1. She was further immobilized unti1 the fracture of the uIna heaIed and then an intensive rehabiIitation program was begun. She was discharged from the hospita1 on December 8, 1949, five months after injury. Figures 5 to 8 show the patient at present. She
has a good functiona recovery of both the hand and the eIbow; there is Iimitation of extension at the eIbow to 120 degrees and weakness in extension of her fingers. She has a usefu1 hand and arm. CASE II. This patient, treated on the same service, was a twenty year oId woman who was in a bus accident on January 16, 1950. At this time, besides numerous other injuries, she received a stocking avuIsion of the skin and subcutaneous tissue of the right lower Ieg. The skin was avuIsed from just beIow the knee and roIIed down intact to the mid-portion of the dista1 one-third of the
American
Journal
of Surgery
Mulholland,
Mahoney-Massive
FIG. 8. Shows degree of healing two and a haIf years after surgery.
AvuIsion
of Skin
361
FIG. IO. Case II. Two years after injury showing healing after repeated split- and fulLthickness grafts. six days after injury. PracticaIIy the entire ffap is necrotic and wiI1 have to be removed. The resurfacing of this Ieg has taken numerous initial spIit grafting operations and finaIIy a cross Ieg Asp, and aImost two years in time before the bony structures have been returned to a favorable environment. The fracture has not united and further major surgery wiII be required before heaIing is compIete. Figure IO shows the Ieg at present just prior to bone grafting.
FIG. 9. Case II. Six days after injury showing extensive necrosis of skin of lower leg which had been replaced by simple suture. Iower leg. There was a1s.o an open fracture of the mid-portion of the tibia and fibula. The patient was admitted in the earIy hours of the morning. The Ieg was carefulIy treated, a11devitaIized tissue removed, the fracture reduced, the tissues carefuIIy irrigated and the skin roIIed back and sutured, having been left attached distaIIy. It is unfortunate that no photograph of the Ieg was taken when the patient was admitted; however, Figure g shows the skin of the avuIsed area
March,
xgp
We believe that the marked contrast these two cases present serves to emphasize the validity of the principle of the management of avuIsed skin by compIete detachment, scraping and replacement as a fuIl-thickness graft. Comparison of the time of heahng is measured in years and certainly the ultimate functiona differences of the affected members will be great. When internes and residents are being trained who soon may be caIIed upon to treat the terrible injuries of battIe, certain surgical principles must be maintained. Although these are pIiabIe and require inteIIigent judgment in application, they must to a certain degree be fixed. With these basic principIes the management of avuIsed flaps of skin by detachment and reapphcation as a graft should be incIuded. In avuIsions of Iesser degree the principle is
362
Mulholland,
Mahoney-Massive
Avulsion
of Skin
FIG. 14. Shows healed flap of the right arm in another case fourteen days after avulsion. FIap rcplncrd by the Farmer method.
FIGS. I I to 13. These illustrate compIete hearing in a patient with avuIsed flap of skin of right hand replaced by the Farmer method. Pictures taken six weeks after injury.
equaJJy true. Figures I I to 13 show the end result of a ffap avuJsion of a hand caught in the roIJer of a baking machine. The flap was lifted from the paJm of the hand, extended around over the first metacarpa1 to the dorsum of the hand and was fixed there by a pedicle. There was associated open fracture of the first metacarpal. The pedicJe attachment was severed, and the skin treated and repraced as a graft with quick and successful heaJing. RehabiJitation of the hand was greatJy faciJitated. Figure 14 shows another patient who had a ffap avuJsion of the arm when it was caught in a roJJer in a Jace miJ1. The skin was attached by a wide pedicle but this was severed and the skin repraced as a graft after preparation. There was a 100 per cent take. The application of this principle extends into other JieIds of surgery in which thin skin flaps of necessity have to be raised. In radical remova1 of the breast where there is very
FIG. 15. Shows we11 heaIed chest waI1 after remova of both breasts for fungating tumor. Denuded art’:, covered with scraped fuII-thickness graft.
meticulous deveJopment of the skin ffaps so that a maximum of fat and subcutaneous tissue is removed, aJmost invariabIy there is some degree of necrosis of the wound edge. We would advocate compJete removal of these Asps, careful scraping and replacing as a graft. In the foIlowing case something similar was done: This woman had advanced cancer between both breasts. She had very penduJous breasts and to remove the fungating mass and cover the area with skin wouJd have required a rather Iarge flap. The Rap was deveIoped from the JateraJ side of the right breast, detached, scraped and repIaced as a full-thickness graft, with success. (Fig. I$.) In summary, we have presented several examples of avulsed skin treated by the method advocated by Dr. Farmer of Toronto. Two of American
Journal
of Surgery
MuIhoIIand,
Mahoney-Massive
these cases were of massive avulsion and by contrast serve to emphasize the basic principIes in the treatment of avulsecl skin. REFERENCES I. FARMER, A. W. Treatment Ann. Surg., I IO: 951-957,
March,
1932
of avulsed 1939.
skin flaps.
AvuIsion
of Skin
363
L. T. Free fd thickness skin grafts. Surfi., 75: 8-20,. 1942. 3. STEVENSON, T. W. J. Principles of treatment of awlsions of skin. S. Clin. Nod Americu, 21:
2.
BYAKS,
(;y?lt'C.r!7 OhSt.,
555-564. 194’. 4. MATHEWSON, C. and GAKBEK, A. Surgical management of extensive avulsions of skin. Am. J. Surg.. 74: 665-676, 1947.
H.
MULHOLLAND,
OF SKIN
M.D. AND JESSE H.
MAHONEY,
M.D.
New York, New York
I
N this mechanized era injuries causing massive avuIsion of skin are not uncommon. On the other hand, such cases are rare enough so that one surgical service sees relatively few cases in comparison to their total admissions. This inexperience may be one explanation for the reIuctance with which the principles of management described by Farmer’ in 1939 have been accepted. There is a natural timidity which must be overcome in detaching avulsed Ilaps of skin from the small blood supply which remains. It has been our experience that a few avulsed skin flaps which are Ieft attached and sutured back into place will survive. A greater number, however, will develop some degree of or complete necrosis. This is particularly true where the avulsion is massive. Objections to replacing contaminated skin as a graft may be discounted if the graft is prepared properly and antibiotics are used. The manner of preparation of the graft does not violate the surgical principle of gentle handling of tissue. No ilI effects result from preparing the graft by scraping with a sharp knife. Even in the most severe injury rarely will the avulsed skin be so badly traumatized that it cannot be employed as a graft. Following are two case histories of patients with massive avulsion of skin, each treated in a different manner. CASE
REPORTS
CASE I. A fifty-one year oId white woman was admitted to the Third (N.Y.U.) SurgicaI Division of Bellevue Hospital on JuIy 5, 1949, after having been struck by a truck, injuring her right arm. Figure I shows the right arm when the patient was placed on the operating table. It may be seen that the patient had an open disIocation of the elbow. The ulna was fractured in its mid-portion but the fragments were in good position. There was aIso an open disIocation of the first and second metacarpophaIangea1 joints. At the eIbow the attachments of the tendons of the common extensors and flexors of the forearm were avulsed, the former carrying a small fragment of bone with it. The vascuIar supply to the arm and the periphera1 nerves were intact. The skin with the subcutaneous tissues was avulsed March,
I 952
from the underlying fascia from the shouIder to the heads of the metacarpaIs. There were numerous lacerations of the detached sIeeve of skin but it was
Fro. I. Case I. Shows extensive avulsion of skin and soft tissues of right arm with compound disIocation of the elbow joint and fracture of the olecranon. attached compIeteIy at the shouIder and distaIIy in the palm of the hand. As soon as the patient’s genera1 condition responded to shock therapy, she was given a genera1 anesthetic and the avuIsed skin was severed from the shouIder and from its attachment in the paIm. The entire sleeve was then split and removed. One team of surgeons proceeded to remove the fat and subcutaneous tissue from the detached skin by scraping with a sharp knife and cutting with scissors. The skin was irrigated with saIine and further bathed with a soIution of peniciIIin containing zoo units per cc. WhiIe this was being accompIished, the traumatized tissues of the arm were carefuIIy debrided by another team. The dislocations were reduced and the muscle attachments about the eIbow fixed in place with line wire sutures. An effort was made to reconstruct the capsule of the joint. A large amount of tissue from the bellies of the common extensor group of muscles of the forearm was devitalized and had to be excised. AI1 superhcia1 fatty tissue was removed from the arm. On compIetion of the debridement the skin which had been prepared was repIaced as a fuIIthickness graft covering the area from just above the insertion of the deItoid to the dorsum of the hand at the heads of the metacarpals. The arm was dressed with thin strips of vaseIine gauze over which sheet wadding was appIied with gentIe, even pressure. The arm was then immobihzed in a plaster
339
MuIhoIIand,
360
Mahoney-Massive
2
FIG.
2.
Case I. Twenty-six
AvuIsion of Skin
3 days after injury showing healing of repIaced graft.
FIG. 3. Another view of same arm.
FIGS.4 to 7. Shows function of arm and degree of healing two and a haIf years after injury. cast from the shouIder to the heads of the metacarpaIs. The cast was removed on the twentysixth postoperative day and the skin was found to be viabIe except for one smaI1 area over the Iateral condyIe which faiIed to heaL Figures 2, 3 and 4 show the patient’s condition at that time. She did very weI1. She was further immobilized unti1 the fracture of the uIna heaIed and then an intensive rehabiIitation program was begun. She was discharged from the hospita1 on December 8, 1949, five months after injury. Figures 5 to 8 show the patient at present. She
has a good functiona recovery of both the hand and the eIbow; there is Iimitation of extension at the eIbow to 120 degrees and weakness in extension of her fingers. She has a usefu1 hand and arm. CASE II. This patient, treated on the same service, was a twenty year oId woman who was in a bus accident on January 16, 1950. At this time, besides numerous other injuries, she received a stocking avuIsion of the skin and subcutaneous tissue of the right lower Ieg. The skin was avuIsed from just beIow the knee and roIIed down intact to the mid-portion of the dista1 one-third of the
American
Journal
of Surgery
Mulholland,
Mahoney-Massive
FIG. 8. Shows degree of healing two and a haIf years after surgery.
AvuIsion
of Skin
361
FIG. IO. Case II. Two years after injury showing healing after repeated split- and fulLthickness grafts. six days after injury. PracticaIIy the entire ffap is necrotic and wiI1 have to be removed. The resurfacing of this Ieg has taken numerous initial spIit grafting operations and finaIIy a cross Ieg Asp, and aImost two years in time before the bony structures have been returned to a favorable environment. The fracture has not united and further major surgery wiII be required before heaIing is compIete. Figure IO shows the Ieg at present just prior to bone grafting.
FIG. 9. Case II. Six days after injury showing extensive necrosis of skin of lower leg which had been replaced by simple suture. Iower leg. There was a1s.o an open fracture of the mid-portion of the tibia and fibula. The patient was admitted in the earIy hours of the morning. The Ieg was carefulIy treated, a11devitaIized tissue removed, the fracture reduced, the tissues carefuIIy irrigated and the skin roIIed back and sutured, having been left attached distaIIy. It is unfortunate that no photograph of the Ieg was taken when the patient was admitted; however, Figure g shows the skin of the avuIsed area
March,
xgp
We believe that the marked contrast these two cases present serves to emphasize the validity of the principle of the management of avuIsed skin by compIete detachment, scraping and replacement as a fuIl-thickness graft. Comparison of the time of heahng is measured in years and certainly the ultimate functiona differences of the affected members will be great. When internes and residents are being trained who soon may be caIIed upon to treat the terrible injuries of battIe, certain surgical principles must be maintained. Although these are pIiabIe and require inteIIigent judgment in application, they must to a certain degree be fixed. With these basic principIes the management of avuIsed flaps of skin by detachment and reapphcation as a graft should be incIuded. In avuIsions of Iesser degree the principle is
362
Mulholland,
Mahoney-Massive
Avulsion
of Skin
FIG. 14. Shows healed flap of the right arm in another case fourteen days after avulsion. FIap rcplncrd by the Farmer method.
FIGS. I I to 13. These illustrate compIete hearing in a patient with avuIsed flap of skin of right hand replaced by the Farmer method. Pictures taken six weeks after injury.
equaJJy true. Figures I I to 13 show the end result of a ffap avuJsion of a hand caught in the roIJer of a baking machine. The flap was lifted from the paJm of the hand, extended around over the first metacarpa1 to the dorsum of the hand and was fixed there by a pedicle. There was associated open fracture of the first metacarpal. The pedicJe attachment was severed, and the skin treated and repraced as a graft with quick and successful heaJing. RehabiJitation of the hand was greatJy faciJitated. Figure 14 shows another patient who had a ffap avuJsion of the arm when it was caught in a roJJer in a Jace miJ1. The skin was attached by a wide pedicle but this was severed and the skin repraced as a graft after preparation. There was a 100 per cent take. The application of this principle extends into other JieIds of surgery in which thin skin flaps of necessity have to be raised. In radical remova1 of the breast where there is very
FIG. 15. Shows we11 heaIed chest waI1 after remova of both breasts for fungating tumor. Denuded art’:, covered with scraped fuII-thickness graft.
meticulous deveJopment of the skin ffaps so that a maximum of fat and subcutaneous tissue is removed, aJmost invariabIy there is some degree of necrosis of the wound edge. We would advocate compJete removal of these Asps, careful scraping and replacing as a graft. In the foIlowing case something similar was done: This woman had advanced cancer between both breasts. She had very penduJous breasts and to remove the fungating mass and cover the area with skin wouJd have required a rather Iarge flap. The Rap was deveIoped from the JateraJ side of the right breast, detached, scraped and repIaced as a full-thickness graft, with success. (Fig. I$.) In summary, we have presented several examples of avulsed skin treated by the method advocated by Dr. Farmer of Toronto. Two of American
Journal
of Surgery
MuIhoIIand,
Mahoney-Massive
these cases were of massive avulsion and by contrast serve to emphasize the basic principIes in the treatment of avulsecl skin. REFERENCES I. FARMER, A. W. Treatment Ann. Surg., I IO: 951-957,
March,
1932
of avulsed 1939.
skin flaps.
AvuIsion
of Skin
363
L. T. Free fd thickness skin grafts. Surfi., 75: 8-20,. 1942. 3. STEVENSON, T. W. J. Principles of treatment of awlsions of skin. S. Clin. Nod Americu, 21:
2.
BYAKS,
(;y?lt'C.r!7 OhSt.,
555-564. 194’. 4. MATHEWSON, C. and GAKBEK, A. Surgical management of extensive avulsions of skin. Am. J. Surg.. 74: 665-676, 1947.