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Severe degloving injury of upper limb
Severe Degloving Injury of Upper L i m b - - M . F. Stranc
SEVERE DEGLOVING INJURY OF UPPER LIMB M. F. STRANC, London This case is presented to illustrate the early management of extensive degloving of the limb, and indicate some of the late sequelae which may develop. On the 18th March, 1966 a three-year-old boy was admitted to Mount Vernon Hospital with a history that earlier that day, he was struck by a lorry and his right arm was run over. Examination on admission revealed a fully conscious and co-operative boy with severe injuries to his right upper limb (Figs. 1 and 2). Examination of the injured limb revealed skin degloving from mid-arm down to mid-forearm. The deep fascia appeared intact above the elbow, but no deep fascia could be seen in the forearm. The muscles in the flexor compartment below the elbow appeared crushed. No peripheral pulses could be felt and the hand was dusky. The hand and fingers were anaesthetic and no voluntary movements could be elicited.
Figs. 1 and 2. Right arm of a three-year-old boy run over by a lorry. After initial resuscitation, the patient was taken to the operating theatre, where total extent of injury was assessed as follows (Fig. 3 ) : - Skin - - extensive skin loss, circumferential in the middle third of the forearm and patchy in the upper arm. Muscles - - bellies of the flexor carpi ulnaris, flexor carpi radialis, flexor digitorum profundus and superficialis, palmaris longus and pronator teres were stripped from the shafts of radius and ulna and tucked under the skin of the dorsum of the hand. Nerves - - both median and ulnar nerves appeared intact and were bowstringing between the elbow and wrist joints. Arteries - - both radial and ulnar arteries were heavily traumatised and divided. Their proximal ends were found crushed in the ante cubital fossa region. Skeleton--Elbowcompound dislocation with disruption of the medial ligament was noted. Long Bones - - the whole of the anterior, medial and posterior surface of ulna were devoid of periosteum. The humerus was stripped of periosteum on its lower and outer aspect. 76
The Hand--Vol. 5
No. 1
1973
Severe Degloving Injury o] Upper Limb--M. F. Stranc
Fig. 3. Arm after excision of dead tissue. The primary treatment involved resection of avulsed muscle bellies which were thought to be non-viable, repair of the capsule and the medial ligament of the elbow and provision of full thickness cover for the area. In view of the uncertain state of the circulation of the hands and fingers, only split skin grafts were used to cover the extensive residual raw surfaces. The patient's post operative progress was satisfactory. The circulation in the hand and fingers became stable and adequate. Seven days after the accident, good take of graft was noted in all areas including bare cortical bone of ulna, where periosteum had been lost (Fig. 4). A large superiorly based, anterior right sided thoraco-abdominal flap, 16 x 10 cms. was raised and used to re-surface the forearm circumferentially (Fig. 5). Eighteen days later, the flap was lengthened, divided and inset fully into the forearm.
Fig. 4. Design of abdominal flap.
Fig. 5. After application of flap.
The child was discharged on the 8th May, 1966, completely healed, with good recovery of sensation in the median nerve distribution. He was able to use his thumb. Sensory recovery and return of function of the hand muscles supplied by the ulnar nerve was complete when the patient was examined in May, 1967. The finger flexor muscles were deficient and only limited mass action of these was possible (Figs. 6 and 7). The Hand--Vol. 5
No. 1
1973
77
Severe Degloving Injury o/ Upper L i m b - - M . F. Stranc
Figs. 6 and 7.
Result after fourteen months.
Subsequent follow up over the ensuing years revealed increasing ulnar deviation of the right wrist. This is almost certainly due to impaired growth of the ulna. Recent X-rays, January 1972, confirm this. DISCUSSION
This case presents several points of interest. It is weU known, that nerve trunks stand up better to severe blunt trauma than other soft tissues. Preservation of continuity of ulnar and median nerves in this case demonstrate this clearly. A good take of split skin graft on the bare cortical bone of the ulnar shaft without its periosteal envelope, is worthy of note. Except in the very young, bare cortical bone is not able to support a free graft. The successful free graft in this case was replaced with a large abdominal flap as it was felt that a safer cover, one through which subsequent surgery could be safely carried out, would be preferable. The dimensions of the skin flap used, base 10 cms., length 16 cms., would appear to transgress safe base to length 1 : 1 ratio for trunk flaps. In young children the rule of 1 : 1 does not apply. Two problems for future management remain, equalisation of the length of the forearm bones and augmentation, if possible, of flexor muscle and tendon action.
78
The H a n d ~ V o l . 5
No. 1
1973
SEVERE DEGLOVING INJURY OF UPPER LIMB M. F. STRANC, London This case is presented to illustrate the early management of extensive degloving of the limb, and indicate some of the late sequelae which may develop. On the 18th March, 1966 a three-year-old boy was admitted to Mount Vernon Hospital with a history that earlier that day, he was struck by a lorry and his right arm was run over. Examination on admission revealed a fully conscious and co-operative boy with severe injuries to his right upper limb (Figs. 1 and 2). Examination of the injured limb revealed skin degloving from mid-arm down to mid-forearm. The deep fascia appeared intact above the elbow, but no deep fascia could be seen in the forearm. The muscles in the flexor compartment below the elbow appeared crushed. No peripheral pulses could be felt and the hand was dusky. The hand and fingers were anaesthetic and no voluntary movements could be elicited.
Figs. 1 and 2. Right arm of a three-year-old boy run over by a lorry. After initial resuscitation, the patient was taken to the operating theatre, where total extent of injury was assessed as follows (Fig. 3 ) : - Skin - - extensive skin loss, circumferential in the middle third of the forearm and patchy in the upper arm. Muscles - - bellies of the flexor carpi ulnaris, flexor carpi radialis, flexor digitorum profundus and superficialis, palmaris longus and pronator teres were stripped from the shafts of radius and ulna and tucked under the skin of the dorsum of the hand. Nerves - - both median and ulnar nerves appeared intact and were bowstringing between the elbow and wrist joints. Arteries - - both radial and ulnar arteries were heavily traumatised and divided. Their proximal ends were found crushed in the ante cubital fossa region. Skeleton--Elbowcompound dislocation with disruption of the medial ligament was noted. Long Bones - - the whole of the anterior, medial and posterior surface of ulna were devoid of periosteum. The humerus was stripped of periosteum on its lower and outer aspect. 76
The Hand--Vol. 5
No. 1
1973
Severe Degloving Injury o] Upper Limb--M. F. Stranc
Fig. 3. Arm after excision of dead tissue. The primary treatment involved resection of avulsed muscle bellies which were thought to be non-viable, repair of the capsule and the medial ligament of the elbow and provision of full thickness cover for the area. In view of the uncertain state of the circulation of the hands and fingers, only split skin grafts were used to cover the extensive residual raw surfaces. The patient's post operative progress was satisfactory. The circulation in the hand and fingers became stable and adequate. Seven days after the accident, good take of graft was noted in all areas including bare cortical bone of ulna, where periosteum had been lost (Fig. 4). A large superiorly based, anterior right sided thoraco-abdominal flap, 16 x 10 cms. was raised and used to re-surface the forearm circumferentially (Fig. 5). Eighteen days later, the flap was lengthened, divided and inset fully into the forearm.
Fig. 4. Design of abdominal flap.
Fig. 5. After application of flap.
The child was discharged on the 8th May, 1966, completely healed, with good recovery of sensation in the median nerve distribution. He was able to use his thumb. Sensory recovery and return of function of the hand muscles supplied by the ulnar nerve was complete when the patient was examined in May, 1967. The finger flexor muscles were deficient and only limited mass action of these was possible (Figs. 6 and 7). The Hand--Vol. 5
No. 1
1973
77
Severe Degloving Injury o/ Upper L i m b - - M . F. Stranc
Figs. 6 and 7.
Result after fourteen months.
Subsequent follow up over the ensuing years revealed increasing ulnar deviation of the right wrist. This is almost certainly due to impaired growth of the ulna. Recent X-rays, January 1972, confirm this. DISCUSSION
This case presents several points of interest. It is weU known, that nerve trunks stand up better to severe blunt trauma than other soft tissues. Preservation of continuity of ulnar and median nerves in this case demonstrate this clearly. A good take of split skin graft on the bare cortical bone of the ulnar shaft without its periosteal envelope, is worthy of note. Except in the very young, bare cortical bone is not able to support a free graft. The successful free graft in this case was replaced with a large abdominal flap as it was felt that a safer cover, one through which subsequent surgery could be safely carried out, would be preferable. The dimensions of the skin flap used, base 10 cms., length 16 cms., would appear to transgress safe base to length 1 : 1 ratio for trunk flaps. In young children the rule of 1 : 1 does not apply. Two problems for future management remain, equalisation of the length of the forearm bones and augmentation, if possible, of flexor muscle and tendon action.
78
The H a n d ~ V o l . 5
No. 1
1973