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Treatment of skin avulsion injuries of the extremities
TREATMENT OF SKIN AVULSION INJURIES OF THE EXTREMITIES By CYRIL O. INNIS, M.B., B.S.
Surgical Registrar, Plastic and Maxillo Facial Unit, St flames's Hospital, Leeds SKIN avulsion injuries of the extremities constitute one of the hazards of modern industrial development and road transport. The earliest reference in recent literature to this type of injury is by Farmer (1939). Most subsequent writings have been by writers in America. The only notable references in the literature of this country are those by Slack (i952) and Prendiville and Lewis (1955). There exist less than ioo recorded cases of this type of injury, and this figure represents only a small percentage of cases which have found their way to specialised Units. The injury is variously described as " roller wringer injury " or " pneumatic tyre torsion avulsion injury." This nomenclature refers to the method by which the injury is produced, whereas in all cases the essential pathology and the principle of treatment are the same. For this reason I use the term " avulsion injury " to include all cases where the skin and subcutaneous tissue is stripped or degloved as a flap from the deeper tissues irrespective of how the injury is sustained. I f the initial treatment of these cases is inadequate there often ensues a prolonged stay in hospital and too often a permanent and crippling deformity with its consequent loss of earning capacity to the individual. This paper is based on twenty cases referred to this Unit over the past twelve months. Ten of these cases were received as " acute injuries " within a few hours of injury, eight were referred at periods varying from one to four weeks later, and two after an interval of one year. 7Etiology.--Skin avulsion injuries are produced by any shearing force which is applied at a tangent to a trapped limb such as occurs when a limb is :-i. Caught in roller-type machinery. 2. Trapped between the wheel of a vehicle and the road surface. As pointed out by Entin (1955) and Slack (1952) the mode of production of the injury is as follows : - (a) Compression of the limb between rollers, or the wheel of a heavy motor vehicle and the road surface. This is followed by (b) " rupture " of the tissue at a point distal to the site of compression and (c) stripping of the skin and subcutaneous tissue of the limb through the fascial plane by a rotating roller or the wheel of a heavy vehicle. This latter force is a " shearing" force and is primarily responsible for the lesion. I f the force stops at (a) then a compression injury results. The severity of the injury is in direct ratio to the weight and speed of the roller or wheel. However, it must be remembered that any shearing force can produce this injury, and in five cases of this series the injury was not caused by roller machinery or the wheel of a vehicle (see Table I, Cases 4 and 7 ; Table II, Cases 4, 5, and IO). 122
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P a t h o l o g y . - - T h e avulsed flap is usually based distally against the normal blood supply and has a narrow base (Fig. I). The subcutaneous fat shows areas of thrombosed blood-vessels and ecchymosis. In the early stages there may not be any marked oedema, but as the venous drainage of the flap is interfered with, passive congestion of the flap results. Added to this there is arterial spasm resulting from the initial trauma. Thus the blood supply to the flap is greatly reduced and
FIG. I Shows avulsed flap r e t u r n e d to its b e d a n d sutured. All m o v e m e n t s at t h e interphalangeal a n d metacarpo-phalangeal joints are limited by deep scarring.
fat necrosis and local gangrene result. Bacterial infection of the wound supervenes, and if the necrosed tissue is not surgically excised at this stage it takes a long time (four to six weeks)~to separate as a slough, leaving a slow-healing granulating area. There may or may not be associated injuries to underlying bone, nerves, and main blood-vessels. As mentioned by Prendivi!le and Lewis, fractures usually occur in those regions where the bones are subcutaneous, e.g., the tibia. In the present'series five cases had associated bone injury (see Table I, Cases 2, 5, and 7 ; Table II, Cases I and 6). The presence or absence of bone injury bears no relation to the extent of soft tissue damage. In only one case of this series was definitive orthopaedic treatment necessary (Table I, Case 2). Fractures should
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be borne in mind and excluded by X-ray. The deep tissues may show areas of hmmatoma, rupture of muscle sheaths, and maceration of muscle tissue. In Illustrative Case I there was a loss of about I in. of the radial nerve in the region of the anatomical snuff-box. I f any portion of the avulsed flap should survive, then the resulting deep scar tissue, formed by organisation of the exudate, is considerable. Fig. I shows a hand in which an avulsed palmar flap was returned to its bed and sutured. Movement at the metacarpo-phalangeal and interphalangeal joints is grossly limited by deep scarring and the hand serves no useful function. T r e a t m e n t . - - T h e cases constituting the present series can be divided into two classes :-x. Those cases seen within a few hours of injury where the flap was excised and skin grafted. 2. Those cases where the flap had been returned to its bed and sutured ; later necrosed, resulting in either a localised area of gangrene corresponding to the outline of the flap, or a granulating area following excision of the necrosed flap. I feel that excision of the flap at its base followed by an immediate skin graft to close the wound is the only suitable method of treatment, and where the general condition of the patient has permitted, this has been carried out. In making a pre-operative assessment it must be borne in mind that these patients have already lost a great deal of blood and in the case of extensive injuries there will be further fluid loss caused by excision of the flaps and the cutting of the skin graft. At operation a pneumatic tourniquet is used in order to make a further detailed examination, in a bloodless field, for any nerve or tendon injury, but it is released as soon as this examination has been completed. A careful debridement of the bed of the flap is then carried out as this is usually contaminated with road or industrial debris. The flap is excised. The excision includes all undermined tissue. An immediate split-skin graft is applied to the defect followed by a pressure dressing. Post-operatively the limb is elevated to reduce (edema and antibiotic therapy is instituted. The first dressing is done on the eighth day, or earlier if there is persistent low-grade pyrexia or pain which cannot otherwise be explained. If at this time there are any areas where the skin has obviously not taken, these areas are excised and free grafts applied to the defects. This does not always entail a further ana:sthetic as skin preserved from the first operation may be used. Cases admitted late, where the flaps have necrosed, are treated by excision of the necrotic area. I f the bed is found unsuitable for accepting a graft (Table II, Cases 2, 3, 4, 6, and IO), skin grafting is delayed, the wound in the meantime being packed with tulle gras and irrigated alternately with Eusol and normal saline. With this method a healthy granulating area eminently suitable for grafting results in about one week (Illustrative Case 2, Fig. 5). Alternatively an unhealthy granulating area is better excised down to a fresh bed and a split-skin graft applied at the same operation (Table II, Cases I and 5). In those cases treated by immediate grafting, physiotherapy by way of active movement is begun on the fourteenth day. Wax baths are given when the graft is well healed and stable. In the cases where a necrosed flap has resulted a degree
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o f j o i n t f i x a t i o n is o f t e n p r e s e n t , i n w h i c h e v e n t i t is a d v i s a b l e f o r p h y s i o t h e r a p y to be begun prior to operation in an attempt to restore joint mobility and muscle
FIG. 2 Shows an avulsion injury over the radial border of the dorsum of the hand, sustained when the limb was trapped in a falling brick wall. The base of the flap is distal and narrow. T h e tendons of the forearm and hand were not exposed. There is loss of about I in. of radial nerve.
FIG. 3 T h e same hand three weeks post-operatively shows 95 per cent. take of graft. Early physiotherapy was instituted affd complete movement regained in three months.
tone. If this is not done, further joint fixation may occur during the period of post-operative immobilisation.
ILLUSTRATIVE CASES Case I.--E. F., female, aged 5 8 years (Figs. 2 and 3). The right hand was trapped in a falling brick wall. Examination on admission the same day showed an avulsed flap extending just proximal to the wrist joint across the radial border of the forearm and
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Avulsion injury treated by suturing of flap to its bed.
FIG. 4 Shows necrosis of the flap following return to its bed and suturing three weeks previously.
Fro. 5 Shows the same leg one week later after excision o f the necrosed flap. A healthy freshly bleeding granulating area suitable for grafting.
FIG. 6 T h e same leg one m o n t h after grafting.
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attached over the dorsum of the wrist. The distal end of the flap measured about 2 in. in diameter narrowing to a base of approximately I½ in. The patient had a full range of finger movements and complained of anmsthesia on the radial border of the index finger. T h e flexor tendons were intact and not exposed. The tendon of the palmaris longus was lacerated as also was the tendon of the brachio-radialis. The radial nerve in the region of the anatomical snuff-box was divided. X-ray revealed a comminuted fracture of the radius I in. from the wrist joint with minimal displacement of the fragments. Treatment.--At operation on the same day the avulsed flap was excised at its base ; contaminated and devitalised tissue was also removed. T h e defect was covered by a split-thickness dermatome graft taken from the left thigh. A pressure dressing was applied to the hand, the limb was elevated, and antibiotics were given post-operatively. Progress.--Dressing eight days later showed approximately 95 per cent. take of the skin graft. The patient was discharged from hospital one month after the operation. Final review three months later showed that there was good movement at the wrist and she could make a full fist. There was, however, loss of radial nerve sensation. Case 2 . - - C . C., female, aged 2 years (Figs. 4, 5, and 6). Three weeks prior to admission the child was involved in a road accident, being knocked down by a heavy motor vehicle. This had resulted in an avulsed flap over the posterior and lateral aspect of her left leg extending from the knee to the ankle joint. The flap was on a broad base situated medially. There was an associated fracture of the fibula. T h e flap was returned to its bed and sutured after an initial toilet. The limb was immobilised in plaster. Three weeks later at the first dressing an extensive area of necrosis was found. At this stage the child was referred to this Unit for treatment. Examination on admission showed an extensive area of necrosis corresponding in outline to the flap. Movements were limited at the knee and ankle joints, apart from which the condition of the limb was satisfactory. Treatment.--At operation the area of necrosis was excised ; pockets of purulent fluid and hmmatoma were found under the flap. It was considered inadvisable to graft skin on this infected bed. The wound was accordingly dressed with Vaseline gauze and irrigated with Eusol. One week later a healthy granulating area resulted and on this skin was grafted. Progress.--The subsequent post-operative course was satisfactory, the grafts took IOO per cent. and the patient was discharged from hospital six weeks from t h e date of transfer. Final review six months later showed healthy stable grafts ; the child was walking well and had a full range of movement at the knee and ankle joints. It was considered that further grafting may be necessary as growth of the limb occurs. Case 3---J. B., male, aged 44 years (Figs. 7, 8, and 9). Occupation : cloth miller. T h e patient was admitted to this Unit two and a half hours after injuring his right hand which was trapped in the roller of a cloth milling machine. This had resulted ill an avulsion injury of the palm of the right hand, the flap extending distally from the wris~ joint involving the entire palm of the hand and palmar aspect of the thumb and based at the level of the metacarpo-phalangeal joints. T h e muscles of the thenar eminence were severed at their insertion, the capsule of the first metacarpo-phalangeal joint was disorganised, and the joint cavity exposed. The flexor tendons were intact and not exposed. T~'eatrnent.--At operation the same day the avulsed flap was excised at its base. Devitalised and contaminated tissue was removed and the capsule of the first metacarpophalangeal ioint was repaired. The defect was covered by means of a split-skin graft. A pressure dressing was applied and the limb elevated. The patient was given antibiotics post-operatively.
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Progress.--The h a n d was dressed one week later. T h i s revealed a small necrotic area o f skin approximately ~ in. square over the t h e n a r eminence, w h i c h was excised and the defect covered with a split-skin graft. T h e pressure dressing was reapplied. Illustrative Case 3- Palmar avulsion injury of the hand.
FiG. 7 Palmar avulsion injury sustained when the hand was caught between rollers of a cloth milling machine. Flap is distally based and is superficial to the palmar aponeurosis. Muscles of the thenar eminence disorganised. The first metacarpophalangeal joint cavity was opened.
FIG. 8 FIG. 9 Figs. 8 and 9.--Result six months post-operatively showing range of movement. P h y s i o t h e r a p y was instituted one week later. H e was discharged f r o m hospital one m o n t h after admission. R e v i e w six m o n t h s later showed that the grafts were stable and pliable. T h e patient
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Dorsal avulsion injury o f t h e h a n d .
FIG~ i0 Shows dorsal avulsion injury of the h a n d sustained w h e n the h a n d was caught b e t w e e n t h e rollers of a printing press, T r e a t e d by i m m e d i a t e excision of t h e flap a n d split-thickness skin graft to t h e defect.
FIG. II
FIG. i2
Figs. I I a n d i 2 . - - T h r e e m o n t h s post-operatively showing a soft pliable graft with a good range of m o v e m e n t .
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illustrative Case 5. Extensive avulsion injury ; both legs treated by primary grafting.
FIG. 13 Severe extensive avulsion injury of both lower limbs sustained when the patient was run over by a bus.
FIG. ~4 The same injury three weeks later, treated by excision of the avulsed flaps and immediate skin grafts.
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had a good range of flexion but the extension was a little weak. The patient is able to write with the hand. (Figs. 8 and 9 show the range of movement after six months.) Case 4 . - - T . C., male, aged 53 years (Figs. 1% I I , and I2). Occupation : printer. The patient was admitted a few hours after having caught his right hand in the steel rollers of a printing press which had resulted in a degloving injury of the dorsum of the hand. Examination showed an extensive laceration across the distal palmar crease. Skin and subcutaneous tissue over the dorsum of the hand were avulsed distally as a flap as far as the metacarpo-phalangeal joints. The extensor tendons were not exposed. --Treatment.--At operation the same day the avulsed flap was excised at its base. The laceration over the palm of the hand was sutured and the defect over the dorsum of the hand was covered by means of a split-skin graft with the fingers placed in flexion. Progress.--Dressing eight days later showed complete take of the skin graft. Physiotherapy was instituted one week later and the patient was discharged four weeks after admission. Final review three months later showed a full range of movement of the fingers and the patient was able to return to his previous employment, working on the same machine. (Figs. I I and I2 show the range of movement.) Case 5.--B. O'C., female, aged 63 years (Figs. 13 and I4). T h e patient was admitted to this Unit immediately after an accident in which she was run over by a bus. She sustained extensive avulsion injuries of both lower limbs. Examination showed : Right Leg.--Extensive avulsion injury extending from above the knee joint to the level of the ankle joint. The injury was circumferential and involved the popliteal fossa, Fro. 15 but there was no damage to the main blood-vessels. This shows scarring which Left Leg.--Circumferential avulsion injury involving occurs in the leg when the the lower two-thirds of the l~ft leg; there was no bone wound heals by granulation. injury. T h e general condition of the patient was satis- Limitation of movement at the ankle joint and a dorsal subfactory in spite of the extensive injury. luxation of the great toe. Treatment.-- At operation on the same day the avulsed flaps were excised; the excision included all undermined tissue. Split-skin grafts taken from the abdomen and thighs were applied. In this way approximately 95 per cent. of the defect was covered. Progress.--The post-operative dressing one week later showed ioo per cent. take of the skin grafts. (Fig. 14 shows the condition of the legs three weeks postoperatively.) Six weeks after operation the legs were completely healed and the patient started walking. She was discharged from hospital eight weeks from the date of injury.
C o m p l i c a t i o n s . - - T h e complications following skin avulsion injuries to the~ excessive scarring w h i c h results if these w o u n d s are allowed to granulanon. T h e s e complications are : - I. Limitation of Joint Movement.--When a scar is situated over a joint the contracting b a n d can be responsible for limitation o f m o v e m e n t and subluxation o f the joint. Arthritic changes can also o c c u r (Fig. 15).
are due heal by surface, produce
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2. (Ndema of the Limb.--Owing to deep scarring and poor lymphatic return, eedema may be observed in the limb distal to the scar. 3. Unstable Scars.--This is fairly frequently seen in these injuries. The scar is liable to ulceration and may undergo malignant degeneration. 4. Loss of Normal Contour of the Limb.--This is due to the absence of subcutaneous fat and is also seen in those cases which have been skin-grafted (Illustrative Case I, Fig. 3, and Illustrative Case 5, Fig. I4). DISCUSSION
All too often an avulsed flap is returned to its bed and sutured in the vain hope that either the whole of it or part of it will survive. This practice is to be strongly condemned. In contrast to the care, planning, and technique which go into the construction of a pedicled flap for any other routine procedure, these avulsed flaps are invariably badly based and raised in a most traumatic manner under adverse conditions. Table II shows that avulsion injuries so treated are very often heavily infected. This can be attributed to the inadequacy of the initial surgical debridement where in an anxious attempt to get primary closure, devitalised tissue is retained. Infection delays the application of skin grafts and diminishes their chance of survival. By immediate excision of the avulsed flap and the application of a split-skin graft we ensure: (a) a more radical debridement; (b) immediate closure of the wound ; (c) diminished chances of sepsis ; (d) reduced scar tissue formation. It is often forgotten that an intact skin surface provides the best barrier against infection, and it should be the aim of the surgeon to re-establish this barrier. In cases of extensive injury, Prendiville and Lewis have advocated immediate excision of the flaps and the delay of skin grafting for one week to allow natural h~emostasis to occur. Against this one must consider the risk of infection in an open wound, and particularly in the aged, the undesirability of two or may be three operations at close intervals. I have found that the bed is most suitable for grafting at the time of the initial operation, that is, at the time of excision of the flaps, and in my opinion the h~emostasis which is observed at the end of one week is that which should normally occur with the application of a pressure dressing following a skin graft. In Illustrative Case 5, an elderly woman with extensive avulsion injuries of both lower limbs, immediate excision of the flaps and skin grafting was carried out. Both legs showed sound healing at the end of six weeks and no further operation was necessary. In cases where an avulsion injury is complicated by a compound fracture, I consider it necessary to treat the avulsion injury first to provide the skin cover. Where there is no actual fracture but the cortical bone is exposed, one of two procedures may be adopted. Either the bone may be left exposed allowing it to cover over by granulation, or it may be pared to produce a freshly bleeding surface on which an epidermal skin graft may be placed in the hope rather than the belief that it will survive. Avulsion injuries of the hand may be considered in two categories : (I) dorsal avulsions and (2) palmar avulsions. Avulsed flaps of the dorsum of the hand which are distally based are better excised and skin-grafted. In dorsal avulsions an important point in the operative procedure is to apply the skin graft with the fingers in flexion ; if this is not done, the final result will be marred by limitation of flexion
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at the metacarpo-phalangeal joints on account of shortage of skin. Palmar avulsions are also treated by excision and grafting. Injuries which are superficial to the palmar aponeurosis accept a graft very well. Some objection may be raised to the sacrifice of the specialised palmar skin and its replacement by a split-skin graft from elsewhere ; however, in the treatment of full-thickness burns of the palm where this is the recognised practice, we know that the skin grafts so applied become stable and pliable, and will stand up to heavy use. There has been a remarkable absence of post-traumatic oedema in hands treated by this method ; this can be attributed to the early institution of physiotherapy which this procedure allows, and to the absence of deep scarring. It should be noted that this line of treatment is not advocated in those cases where tendons or underlying bone is exposed. These injuries require more elaborate pedicled flaps to obtain cover. Farmer (1939) suggested that the flap should be excised at its base, the subcutaneous fat removed, and the skin replaced as a Wolfe graft. I have not attempted this method of treatment. The objection I hold to this is that a bruised and traumatised Wolfe graft is used, whereas a freshly cut split-skin graft would have a better chance of survival. Other writers have suggested that all non-viable tissue should be excised and the flap returned to its bed and sutured. I feel that one can never be certain of the circulation in these flaps and that a flap which would appear viable at the time of operation will, in forty-eight hours, show necrosis. The only way in which one can be certain that all non-viable tissue has been removed is to excise it from its base. Some other writers have advocated delay in suturing the flap for forty-eight hours in order to ascertain the blood supply, but this I feel in no way increases ,the chances of survival of the flap and merely leaves an open wound. SUMMARY Twenty cases of avulsion injuries of the extremities are presented. The treatment of this type of injury by excision of the entire avulsed flap, and where the patient's general condition permits, the application of an immediate split-skin graft, is advocated as the treatment of choice. There has been observed a remarkable absence of deep scarring and post-traumatic cedema in the limbs treated by this method. The period of in-patient treatment is reduced and the functional result is more successful. I wish to thank Mr Michael C. Oldfield and Mr Mortimer H. Shaw .for the interest and advice ~-hey have extended in the preparation of this paper. I also wish to thank Mr John Hainsworth and Miss Cecelia Campbell of the Department of Medical Photography, St James' s Hospital, Leeds, for the excellent coloured photographs.
REFERENCES ! ENTIN, M. A. (I955). Plast. reconstruct. Surg., 15,290. FARMER, A. W. (I939). Ann. Surg., ~rlo, 951.
PR~XmVlLLE,J. B., and LEwis,E. (1955). Brit. J. Surg., 42, 582. SLACK,C. C. (I952). Brit. reed. J., 2, 262.
L e f t l e g - - a v u l s i o n injury extending f r o m I in. above t h e knee joint to t h e toes. T h e injury was circumferential in its entire extent. Circulation of the limbs, however, was good. Associated c o m p o u n d fracture left tibia Right lower l i m b - a v u l s e d flap o v e r posterior aspect o f right thigh. Assod a t e d closed fracture of right tibia. Intraabdominal injuries suspected at first examination A v u l s e d flap excised. A v u l s e d flap 3 by 2½ in. over d o r s u m of the Immediate splith a n d , based d i s t a l l y [ thickness graft to at t h e level of t h e defect metacarpo-phalangeal i joints. E x t e n s o r ten- I dons n o t exposed I
R u n over by a b u s
H a n d caught in t h e wringer of a w a s h ing m a c h i n e
Case 3 . - - F e m a l e , 63 years
W o u n d toilet a n d excision of what was considered nonviable tissue carried out at an e m e r g e n c y operation on day of admission. D r e s s i n g one week later showed further necrosis of flaps. F u r t h e r excision carried out. T r a n s f e r r e d to this U n i t ten days after injury. H m m o globin 5 ° per cent. Blood transfused. Injuries of b o t h limbs skin-grafted in one operation
W o u n d toilet a n d excision o f flap carried out at local hospital. Transferred four days later to this Unit. O n e week later split-thickness skin grafts applied
Case 2 . - - M a l e , 7 years
L a r g e avulsed flap 8"by 8 in. over lateral aspect of right thigh. Flap was non-viable
K n o c k e d off a bicycle b y a heavy m o t o r vehicle. Right thigh trapped between t h e road surface a n d wheel o f the vehicle
Surgical T r e a t m e n t .
Case I . - - M a l e , 13 years
D e s c r i p t i o n of Injury.
M e c h a n i s m of Injury.
Sex a n d Age.
E i g h t weeks. Full r a n g e of m o v e m e n t . Grafts stabie. Able to do all h e r h o u s e work
Twelveweeks. Showed good healing. Grafts taken well. T h e fractures of the right a n d left tibia h a d united. R a n g e o f m o v e m e n t at left knee I8O to 90 degrees. Child h a d started to walk with sticks
Six weeks. A p p r o x i mately 90 p e r cent. take o f grafts. R e ferred back for f u r t h e r orthopmdic care
F o u r weeks. H u n d r e d per cent. take of skin graft. P h y s i o therapy started two weeks postoperatively. Discharged with good range of m o v e m e n t . P h y s i o t h e r a p y cont i n u e d as out-patient
T w e l v e weeks. Graft stable and well healed. Child taking an active part in all school sports
Final Review.
F o u r weeks. H u n d r e d p e r cent. take o f grafts. Patient discharged h o m e with full range of movement
Period of I n - p a t i e n t Treatment and Progress.
TABLE I Summaries of Cases treated by immediate Excision of the Flap and Split-skin Graft to the Defect
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R i g h t h a n d caught between two rotat'~ng steel rol]ers
R u n over by a b u s
Case 6 . - - F e m a l e ,
P u s h e d right h a n d through a window
5.--Male,
63 years
39 years
Case
4.~Male, 15 years
Case
R i g h t leg - - extensive avulsion injury ext e n d i n g from above t h e knee to t h e ankle joint and involving t h e popliteal fossa. T h e injury was circumferential in its entire extent L e f t l e g - - a v u l s i o n injury involving the lower two - thirds, also circumferential in its entire extent. N o injury to bones or m a i n blood-vessels in spite of the extent of the iniury
A v u l s e d flap of palmar skin size 3 by 3 in., distally based at t h e level of the m e t a carpal joints. The d e p t h of the skin loss is superficial to t h e t e n d o n s w h i c h were n o t e x p o s e d . Fracture of the shaft of the f o u r t h metacarpal ; no displacement of fragments. Absence of nerve a n d t e n d o n injury
A v u l s e d flap over flexor aspect of distal third o f forearm, size 3 by z½ in. Ulnar and m e d i a n nerves intact. Palmaris longus tendon exposed
All avulsed flaps a n d undermined tissue excised. N i n e t y per cent. of t h e area grafted at initial operation. Further grafting three weeks later to expedite healing of r e m a i n i n g areas
A v u l s e d flap excised. Split-skin graft to defect. T w e n t y - f i v e per cent. loss o f graft necessitated f u r t h e r grafting eight days after p r i m a r y operation
A v u l s e d flap excised. Palmaris longus tend o n also excised a n d i m m e d i a t e split-skin graft applied to t h e defect
Eight weeks. All grafts took Ioo p e r cent. Complete healing in six weeks
Five weeks. Successful take o f s u b sequent graft. Physiotherapy started three weeks after p r i m a r y operation. Discharge delayed on account of slow initial response to physiotherapy
T w o weeks. H u n d r e d per cent. take of skin graft. P h y s i o therapy started two weeks postoperatively. Discharged w i t h good range of movement. Physiotherapy continued
Twelve weeks. Walking without difficulty. Loss of n o r m a l contour o f limbs
T w e l v e weeks. Skin graft soft, pliable, a n d freely mobile over deeper tissues. H a s approximately 9o degrees flexion at metacarpophalangeal joint a n d 45 degrees at interphalangeal joints. R e m a r k a b l e absence of oedema of h a n d s a n d fingers
E i g h t weeks. Full range o f m o v e m e n t . Grafts stable a n d wound remained healed
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x
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H a n d c r u s h e d by a falling brick w a l l Details of accident n o t available
H a n d caught between steel rollers of a cloth milling machine
Case 7 . - - F e m a l e ,
Case
R i g h t foot r u n over by t h e wheel o f a m o t o r car
Case I o . - - F e m a l e ,
16 years
H a n d caught between the steel rollers of a p r i n t i n g press
9.--Male, 53 years
Case
8.--Male, 44 years
58 years
M e c h a n i s m of I n j u r y
Sex a n d Age.
A v u l s e d flap based distally over the d o r s u m o f right foot. Size 2 by 3 in.
A v u l s e d flap over dors u m of right h a n d ; laceration across the distal palmar crease ; t e n d o n s were n o t exposed. N o associated nerve or bone injury.
A v u l s e d flap right h a n d baseddistally, involving entire p a l m a n d thumb. The thenar muscles were severed. Capsule o f m e t a carpo - phalangeal joint disorganised a n d joint cavity exposed. T h e t e n d o n s were n o t exposed. No associated t e n d o n or nerve injury
A v u l s e d flap 6 by 2 in. c o m m e n c i n g on t h e distal third flexor aspect o f right forearm, extending across t h e radial border of the forearm, based on t h e d o r s u m of t h e h a n d distal to t h e wrist joint. Associated Colles' fracture. No displacement. Radial nerve a n d artery severed in t h e region of t h e anatomical snuff-box
D e s c r i p t i o n o f Injury.
I m m e d i a t e excision of t h e flap a n d splitskin graft to t h e defect
A v u l s e d dorsal flap excised at its distal attachment. Splitskin graft applied to defect
Joint capsule of first metacarpo - phalangeal joint r e p a i r e d ; entire flap excised. Split-skin graft applied to t h e defect
Excision of flap a n d i m m e d i a t e split-skin graft after careful d e b r i d e m e n t of t h e w o u n d . T h e severed ends of t h e radial n e r v e could n o t be isolated for repair
Surgical T r e a t m e n t .
TABLE I--continued
T h r e e weeks. C o m plete take of sldn graft
T h r e e weeks. Full take of skin graft. Physiotherapy started two weeks post-operatively
F o u r weeks. Full take of grafts. Ninety-five per cent. take o f grafts. A p p r o x i m a t e l y ½ in. square of loss over thenar eminence required grafting at first dressing. Physiotherapy started two weeks post-operatively
F o u r weeks. N i n e t y five per cent. take o f graft. Discharged. P h y s i o t h e r a p y cont i n u e d as out-patient
Period of I n - p a t i e n t Treatment and Progress.
Six m o n t h s . Sound healing. Able to walk without difficulty
T h r e e m o n t h s . Graft stable a n d pliable. C a n m a k e a full fist a n d r e t u r n to full e m p l o y m e n t , working on t h e same machine
Six m o n t h s . Grafts stable and pliable. A p p r o x i m a t e l y full range of m o v e m e n t in all fingers. Is able to write with this h a n d
Twelve weeks. Full r a n g e of finger a n d wrist m o v e m e n t , i Graft stable. H o w - : ever there is a loss of t h e n o r m a l cont o u r of t h e h a n d at t h e site of injury owing to the absence 1 of subluxafion tissue
Final Review.
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Review three months later. Area had r e m a i n e d healed. Grafts stable. Full range of movement at the knee joint. (Edema of the leg below the grafted area noted at time of discharge was absent
Grafts healed. Stable. No residualdisability
Ten weeks. Grafts took Ioo per cent. D i s c h a r g e d five weeks after skingrafting. (Edema of the foot and ankle noticed at time of discharge. Physiotherapy continued as out-patient
Flap resutured to its ~ Four months. The wound was heavily bed. Transferred contaminated with twelve days later. Ps. pyocyaneus. This Examination showed delayed grafting for necrosis of the entire three weeks. Grafts flap w h i c h was applied three weeks heavily infected. later which took Flap excised. Splitwell. In-patient skin grafts applied treatment was prothree weeks later longed by poor general condition, the patient developing a pleural effusion during this time Eight weeks. Full take of skin graft. Walking without discomfort at time of discharge
Flap returned to its bed and sutured, later necrosed, and was excised. Transferred four weeks after injury. The granulating area was excised down to a fresh bed and splitskin grafts applied
Avulsed flap size 8 by 6 in. over the lateral aspect of the left leg and heel. Associated fracture mid-shaft of fibula
Avulsed flap extending from the lower third posterior aspect of right thigh across the popliteal fossa to junction of the upper and mid-third of the calf. No associated bony injury
Avulsed flap 2 in. diameter over lateral aspect of foot
L e f t leg c r u s h e d between the wheel of a heavy motor vehicle and a brick wall
Knocked down by a heavy motor vehicle
Right foot trapped between the curb and the wheel of a motor cycle
Case I.--Female, 36 years
Case a.--Female, 76 years
Case 3.--Male, 42 years
Flap resutured to its bed, later necrosed. Seen three weeks later at this Unit. Granulating area 2 in. diameter. This was excised and grafted one week later
Review four months later showed stable and pliable grafts. (Edema of the foot and ankle had subsided. Was walking well without any disability
Period of In-patient Treatment and Progress.
Surgical Treatment.
Description of Injury.
Mechanism of Injury.
Sex and Age.
Final Review.
Summaries of Cases where Necrosis of the Flap Resulted following Suture of the Flap to its Bed
TABLE II
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Six m o n t h s . No residual deformity. Grafted area remained healed s i x weeks post-operatively
Six months. Area well healed. Child walking well. May require further grafting as growth of the limb takes place
Three months. Prognosis poor. There is a hope that at a later date pollicisation of the middle finger can be attempted
Seven weeks. Successful take of graft. Discharged four weeks after admission to Unit
Eight weeks. Grafts took IOO per cent., subsequent grafting unnecessary
Flap sutured to its bed, later necrosed, and was excised. Transferred to this Unit three weeks after receipt of injury. Granulating area excised down to a fresh bed. Split-skin graft applied Flap returned to its bed and sutured. Necrosis of the flap appeared two weeks later. Transferred to this Unit. Necrosed flap excised ; grafted one week later
]-shaped flap extending from I in. above the knee to the level of the ankle joint, situated over the anterior aspect of the left leg, flap based medially. There was an associated fracture of the left fibula
Extensive avulsion in- Poor general condition Twelve weeks. Grafted areas healed well but delayed surgery for jury involving both the mdema of the four weeks. Splitpalmar and dorsal index and middle skin grafts applied aspects of left hand. fingers remained six weeks after reThe capsule of the first metacarpoceipt of injury phalangeal joint was disorganised, joint cavity exposed. Skin flaps were returned to their bed and sutured. Cyanosis of the ring and little fingers necessitated amputation of these digits three days later, followed by amputation of the thumb and necrosed flaps one week later. Transferred to this Unit at this stage. Examination showed marked 0edema of the remaining digits, i.e., index and middle, and an extensive granulating area of the palm and dorsum of the hand. Area heavily infected
Run over by a heavy motor vehicle
Run over by a heavy motor vehide
Case 6.--Female, 2 years
Case 7 . - - M a l e , 2 years
i
Inverted V-shaped flap over the upper onethird of the anterior aspect of the left thigh, size 3 by 3 in., based distally
Injury sustained when tobogganing
Six m o n t h s . No residual disability. Grafted area remained healed
Case 5 . - - M a l e , 11 years
Eleven weeks. Skingrafting delayed for t h r e e w e e k s on account of wound infection. Initial grafts took 5° per cent., subsequent grafting successful
Final Review.
V-shaped flap 2 by 2 in. right leg, based distally. V-shaped flap 2 by 3 in. left leg, based laterally. No associated bony injury
I Avulsed flaps sutured I to their bed. TransI ferred to this Unit i one week later when necrosis set in. Flaps excised and skin i grafted after three weeks and further grafting two weeks later i
Period of In-patient Treatment and Progress.
cellar
Surgical Treatment.
escription of Injury.
Fell down steps
Mechanism of Injury.
Case 4.--Female, 64 years
Sex and Age.
TABLE I I - - c o n t i n u e d
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Fell out of a m o t o r car a n d was r u n over
R u n over b y a heavy m o t o r vehicle
Case 8 . - - F e m a l e , 49 years
Case 9,--Male, 4 years
T h e scar was excised and the defect covered by split-skin grafts
L a r g e a v u l s e d flap T h e area of h y p e r trophic scar over t h e based laterally over d o r s u m of the foot the lower half of ana n d leg was excised. terior aspect of right The defect was leg a n d d o r s u m o f covered by a splitright foot. Size 9 by skin graft. A 3 in. Flap was ret e n o t o m y was also t u r n e d to its b e d a n d p e r f o r m e d to correct sutured. Necrosis of the dorsal s u b l u x a t h e flap occurred a n d the resulting w o u n d tion of the great toe healed by granulation in three months. Referred to this U n i t after one year. T h e r e was m a r k e d hypertrophic, scarring of t h e d o r s u m of the foot a n d lower o n e - t h i r d of t h e right leg. T h e r e was a dorsal sublmxation of the great toe (Fig. I5). Plantar flexion of the a n k l e i o i n t w a s limited by I5 degrees
Extensive avulsion iniury to left leg involving the entire medial aspect. The flap was r e t u r n e d to its bed and sutured, later necrosed, and t h e resulting w o u n d was allowed to heal by granulation, taking five m o n t h s for c o m p l e t e h e a l i n g . Referred to this U n i t two years later c o m plaining of swelling of the left foot a n d discomfort due to tightness in the region of t h e scar. T h e scar itself was p a p e r - t h i n in places and subject to ulceration F o u r weeks. Followi n g excision o f t h e hypertrophic scar the area was well healed and the ~,patient was discharged
T h r e e weeks. Grafts took IOO per cent. W a s able to walk w i t h o u t difficulty at time of discharge
T h r e e m o n t h s . Grafts stable a n d t h e child was walking well w i t h o u t a n y disability
T h r e e m o n t h s . O~dema absent. Grafts stable. Patient walking well
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Left forearm injured while j u m p i n g off a brick wall. (Details n o t r e m e m b e r e d by patient)
Case I o . - - M a l e ,
2 7 years
M e c h a n i s m of Injury.
Sex a n d Age.
Large avulsed flap inverted V in shape situated over t h e anterior aspect o f t h e u p p e r half of t h e left forearm, size 8 b y 4 in. Flap was ret u r n e d to its b e d a n d sutured. Necrosis o f t h e flap was observed forty-eight hours later a n d was well defined in one week. T r a n s f e r r e d to this U n i t eight days after injury. E x a m i n a t i o n showed area of necrosis over anterior aspect o f a r m corres p o n d i n g in outline to t h e original flap
D e s c r i p t i o n of Injury.
TABLE
T h e necrosed flap was excised a week later a n d a split-skin graft applied
Surgical T r e a t m e n t .
II--continued
Six weeks. T h e skin graft took ioo p e r cent. T h e patient was discharged four weeks after a d m i s sion to this U n i t
Period of I n - p a t i e n t Treatment and Progress.
T h r e e m o n t h s . Grafts stable a n d healthy. F u l l m o v e m e n t in left h a n d . N o residual deformity
Final Review.
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Surgical Registrar, Plastic and Maxillo Facial Unit, St flames's Hospital, Leeds SKIN avulsion injuries of the extremities constitute one of the hazards of modern industrial development and road transport. The earliest reference in recent literature to this type of injury is by Farmer (1939). Most subsequent writings have been by writers in America. The only notable references in the literature of this country are those by Slack (i952) and Prendiville and Lewis (1955). There exist less than ioo recorded cases of this type of injury, and this figure represents only a small percentage of cases which have found their way to specialised Units. The injury is variously described as " roller wringer injury " or " pneumatic tyre torsion avulsion injury." This nomenclature refers to the method by which the injury is produced, whereas in all cases the essential pathology and the principle of treatment are the same. For this reason I use the term " avulsion injury " to include all cases where the skin and subcutaneous tissue is stripped or degloved as a flap from the deeper tissues irrespective of how the injury is sustained. I f the initial treatment of these cases is inadequate there often ensues a prolonged stay in hospital and too often a permanent and crippling deformity with its consequent loss of earning capacity to the individual. This paper is based on twenty cases referred to this Unit over the past twelve months. Ten of these cases were received as " acute injuries " within a few hours of injury, eight were referred at periods varying from one to four weeks later, and two after an interval of one year. 7Etiology.--Skin avulsion injuries are produced by any shearing force which is applied at a tangent to a trapped limb such as occurs when a limb is :-i. Caught in roller-type machinery. 2. Trapped between the wheel of a vehicle and the road surface. As pointed out by Entin (1955) and Slack (1952) the mode of production of the injury is as follows : - (a) Compression of the limb between rollers, or the wheel of a heavy motor vehicle and the road surface. This is followed by (b) " rupture " of the tissue at a point distal to the site of compression and (c) stripping of the skin and subcutaneous tissue of the limb through the fascial plane by a rotating roller or the wheel of a heavy vehicle. This latter force is a " shearing" force and is primarily responsible for the lesion. I f the force stops at (a) then a compression injury results. The severity of the injury is in direct ratio to the weight and speed of the roller or wheel. However, it must be remembered that any shearing force can produce this injury, and in five cases of this series the injury was not caused by roller machinery or the wheel of a vehicle (see Table I, Cases 4 and 7 ; Table II, Cases 4, 5, and IO). 122
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P a t h o l o g y . - - T h e avulsed flap is usually based distally against the normal blood supply and has a narrow base (Fig. I). The subcutaneous fat shows areas of thrombosed blood-vessels and ecchymosis. In the early stages there may not be any marked oedema, but as the venous drainage of the flap is interfered with, passive congestion of the flap results. Added to this there is arterial spasm resulting from the initial trauma. Thus the blood supply to the flap is greatly reduced and
FIG. I Shows avulsed flap r e t u r n e d to its b e d a n d sutured. All m o v e m e n t s at t h e interphalangeal a n d metacarpo-phalangeal joints are limited by deep scarring.
fat necrosis and local gangrene result. Bacterial infection of the wound supervenes, and if the necrosed tissue is not surgically excised at this stage it takes a long time (four to six weeks)~to separate as a slough, leaving a slow-healing granulating area. There may or may not be associated injuries to underlying bone, nerves, and main blood-vessels. As mentioned by Prendivi!le and Lewis, fractures usually occur in those regions where the bones are subcutaneous, e.g., the tibia. In the present'series five cases had associated bone injury (see Table I, Cases 2, 5, and 7 ; Table II, Cases I and 6). The presence or absence of bone injury bears no relation to the extent of soft tissue damage. In only one case of this series was definitive orthopaedic treatment necessary (Table I, Case 2). Fractures should
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be borne in mind and excluded by X-ray. The deep tissues may show areas of hmmatoma, rupture of muscle sheaths, and maceration of muscle tissue. In Illustrative Case I there was a loss of about I in. of the radial nerve in the region of the anatomical snuff-box. I f any portion of the avulsed flap should survive, then the resulting deep scar tissue, formed by organisation of the exudate, is considerable. Fig. I shows a hand in which an avulsed palmar flap was returned to its bed and sutured. Movement at the metacarpo-phalangeal and interphalangeal joints is grossly limited by deep scarring and the hand serves no useful function. T r e a t m e n t . - - T h e cases constituting the present series can be divided into two classes :-x. Those cases seen within a few hours of injury where the flap was excised and skin grafted. 2. Those cases where the flap had been returned to its bed and sutured ; later necrosed, resulting in either a localised area of gangrene corresponding to the outline of the flap, or a granulating area following excision of the necrosed flap. I feel that excision of the flap at its base followed by an immediate skin graft to close the wound is the only suitable method of treatment, and where the general condition of the patient has permitted, this has been carried out. In making a pre-operative assessment it must be borne in mind that these patients have already lost a great deal of blood and in the case of extensive injuries there will be further fluid loss caused by excision of the flaps and the cutting of the skin graft. At operation a pneumatic tourniquet is used in order to make a further detailed examination, in a bloodless field, for any nerve or tendon injury, but it is released as soon as this examination has been completed. A careful debridement of the bed of the flap is then carried out as this is usually contaminated with road or industrial debris. The flap is excised. The excision includes all undermined tissue. An immediate split-skin graft is applied to the defect followed by a pressure dressing. Post-operatively the limb is elevated to reduce (edema and antibiotic therapy is instituted. The first dressing is done on the eighth day, or earlier if there is persistent low-grade pyrexia or pain which cannot otherwise be explained. If at this time there are any areas where the skin has obviously not taken, these areas are excised and free grafts applied to the defects. This does not always entail a further ana:sthetic as skin preserved from the first operation may be used. Cases admitted late, where the flaps have necrosed, are treated by excision of the necrotic area. I f the bed is found unsuitable for accepting a graft (Table II, Cases 2, 3, 4, 6, and IO), skin grafting is delayed, the wound in the meantime being packed with tulle gras and irrigated alternately with Eusol and normal saline. With this method a healthy granulating area eminently suitable for grafting results in about one week (Illustrative Case 2, Fig. 5). Alternatively an unhealthy granulating area is better excised down to a fresh bed and a split-skin graft applied at the same operation (Table II, Cases I and 5). In those cases treated by immediate grafting, physiotherapy by way of active movement is begun on the fourteenth day. Wax baths are given when the graft is well healed and stable. In the cases where a necrosed flap has resulted a degree
SKIN
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o f j o i n t f i x a t i o n is o f t e n p r e s e n t , i n w h i c h e v e n t i t is a d v i s a b l e f o r p h y s i o t h e r a p y to be begun prior to operation in an attempt to restore joint mobility and muscle
FIG. 2 Shows an avulsion injury over the radial border of the dorsum of the hand, sustained when the limb was trapped in a falling brick wall. The base of the flap is distal and narrow. T h e tendons of the forearm and hand were not exposed. There is loss of about I in. of radial nerve.
FIG. 3 T h e same hand three weeks post-operatively shows 95 per cent. take of graft. Early physiotherapy was instituted affd complete movement regained in three months.
tone. If this is not done, further joint fixation may occur during the period of post-operative immobilisation.
ILLUSTRATIVE CASES Case I.--E. F., female, aged 5 8 years (Figs. 2 and 3). The right hand was trapped in a falling brick wall. Examination on admission the same day showed an avulsed flap extending just proximal to the wrist joint across the radial border of the forearm and
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Avulsion injury treated by suturing of flap to its bed.
FIG. 4 Shows necrosis of the flap following return to its bed and suturing three weeks previously.
Fro. 5 Shows the same leg one week later after excision o f the necrosed flap. A healthy freshly bleeding granulating area suitable for grafting.
FIG. 6 T h e same leg one m o n t h after grafting.
SKIN AVULSION INJURIES OF THE EXTREMITIES
~27
attached over the dorsum of the wrist. The distal end of the flap measured about 2 in. in diameter narrowing to a base of approximately I½ in. The patient had a full range of finger movements and complained of anmsthesia on the radial border of the index finger. T h e flexor tendons were intact and not exposed. The tendon of the palmaris longus was lacerated as also was the tendon of the brachio-radialis. The radial nerve in the region of the anatomical snuff-box was divided. X-ray revealed a comminuted fracture of the radius I in. from the wrist joint with minimal displacement of the fragments. Treatment.--At operation on the same day the avulsed flap was excised at its base ; contaminated and devitalised tissue was also removed. T h e defect was covered by a split-thickness dermatome graft taken from the left thigh. A pressure dressing was applied to the hand, the limb was elevated, and antibiotics were given post-operatively. Progress.--Dressing eight days later showed approximately 95 per cent. take of the skin graft. The patient was discharged from hospital one month after the operation. Final review three months later showed that there was good movement at the wrist and she could make a full fist. There was, however, loss of radial nerve sensation. Case 2 . - - C . C., female, aged 2 years (Figs. 4, 5, and 6). Three weeks prior to admission the child was involved in a road accident, being knocked down by a heavy motor vehicle. This had resulted in an avulsed flap over the posterior and lateral aspect of her left leg extending from the knee to the ankle joint. The flap was on a broad base situated medially. There was an associated fracture of the fibula. T h e flap was returned to its bed and sutured after an initial toilet. The limb was immobilised in plaster. Three weeks later at the first dressing an extensive area of necrosis was found. At this stage the child was referred to this Unit for treatment. Examination on admission showed an extensive area of necrosis corresponding in outline to the flap. Movements were limited at the knee and ankle joints, apart from which the condition of the limb was satisfactory. Treatment.--At operation the area of necrosis was excised ; pockets of purulent fluid and hmmatoma were found under the flap. It was considered inadvisable to graft skin on this infected bed. The wound was accordingly dressed with Vaseline gauze and irrigated with Eusol. One week later a healthy granulating area resulted and on this skin was grafted. Progress.--The subsequent post-operative course was satisfactory, the grafts took IOO per cent. and the patient was discharged from hospital six weeks from t h e date of transfer. Final review six months later showed healthy stable grafts ; the child was walking well and had a full range of movement at the knee and ankle joints. It was considered that further grafting may be necessary as growth of the limb occurs. Case 3---J. B., male, aged 44 years (Figs. 7, 8, and 9). Occupation : cloth miller. T h e patient was admitted to this Unit two and a half hours after injuring his right hand which was trapped in the roller of a cloth milling machine. This had resulted ill an avulsion injury of the palm of the right hand, the flap extending distally from the wris~ joint involving the entire palm of the hand and palmar aspect of the thumb and based at the level of the metacarpo-phalangeal joints. T h e muscles of the thenar eminence were severed at their insertion, the capsule of the first metacarpo-phalangeal joint was disorganised, and the joint cavity exposed. The flexor tendons were intact and not exposed. T~'eatrnent.--At operation the same day the avulsed flap was excised at its base. Devitalised and contaminated tissue was removed and the capsule of the first metacarpophalangeal ioint was repaired. The defect was covered by means of a split-skin graft. A pressure dressing was applied and the limb elevated. The patient was given antibiotics post-operatively.
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Progress.--The h a n d was dressed one week later. T h i s revealed a small necrotic area o f skin approximately ~ in. square over the t h e n a r eminence, w h i c h was excised and the defect covered with a split-skin graft. T h e pressure dressing was reapplied. Illustrative Case 3- Palmar avulsion injury of the hand.
FiG. 7 Palmar avulsion injury sustained when the hand was caught between rollers of a cloth milling machine. Flap is distally based and is superficial to the palmar aponeurosis. Muscles of the thenar eminence disorganised. The first metacarpophalangeal joint cavity was opened.
FIG. 8 FIG. 9 Figs. 8 and 9.--Result six months post-operatively showing range of movement. P h y s i o t h e r a p y was instituted one week later. H e was discharged f r o m hospital one m o n t h after admission. R e v i e w six m o n t h s later showed that the grafts were stable and pliable. T h e patient
SKtN
AVULSION
Illustrative Case 4.
INJURIES
OF
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Dorsal avulsion injury o f t h e h a n d .
FIG~ i0 Shows dorsal avulsion injury of the h a n d sustained w h e n the h a n d was caught b e t w e e n t h e rollers of a printing press, T r e a t e d by i m m e d i a t e excision of t h e flap a n d split-thickness skin graft to t h e defect.
FIG. II
FIG. i2
Figs. I I a n d i 2 . - - T h r e e m o n t h s post-operatively showing a soft pliable graft with a good range of m o v e m e n t .
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illustrative Case 5. Extensive avulsion injury ; both legs treated by primary grafting.
FIG. 13 Severe extensive avulsion injury of both lower limbs sustained when the patient was run over by a bus.
FIG. ~4 The same injury three weeks later, treated by excision of the avulsed flaps and immediate skin grafts.
SKIN AVULSION INJURIES OF THE EXTREMITIES
i3i
had a good range of flexion but the extension was a little weak. The patient is able to write with the hand. (Figs. 8 and 9 show the range of movement after six months.) Case 4 . - - T . C., male, aged 53 years (Figs. 1% I I , and I2). Occupation : printer. The patient was admitted a few hours after having caught his right hand in the steel rollers of a printing press which had resulted in a degloving injury of the dorsum of the hand. Examination showed an extensive laceration across the distal palmar crease. Skin and subcutaneous tissue over the dorsum of the hand were avulsed distally as a flap as far as the metacarpo-phalangeal joints. The extensor tendons were not exposed. --Treatment.--At operation the same day the avulsed flap was excised at its base. The laceration over the palm of the hand was sutured and the defect over the dorsum of the hand was covered by means of a split-skin graft with the fingers placed in flexion. Progress.--Dressing eight days later showed complete take of the skin graft. Physiotherapy was instituted one week later and the patient was discharged four weeks after admission. Final review three months later showed a full range of movement of the fingers and the patient was able to return to his previous employment, working on the same machine. (Figs. I I and I2 show the range of movement.) Case 5.--B. O'C., female, aged 63 years (Figs. 13 and I4). T h e patient was admitted to this Unit immediately after an accident in which she was run over by a bus. She sustained extensive avulsion injuries of both lower limbs. Examination showed : Right Leg.--Extensive avulsion injury extending from above the knee joint to the level of the ankle joint. The injury was circumferential and involved the popliteal fossa, Fro. 15 but there was no damage to the main blood-vessels. This shows scarring which Left Leg.--Circumferential avulsion injury involving occurs in the leg when the the lower two-thirds of the l~ft leg; there was no bone wound heals by granulation. injury. T h e general condition of the patient was satis- Limitation of movement at the ankle joint and a dorsal subfactory in spite of the extensive injury. luxation of the great toe. Treatment.-- At operation on the same day the avulsed flaps were excised; the excision included all undermined tissue. Split-skin grafts taken from the abdomen and thighs were applied. In this way approximately 95 per cent. of the defect was covered. Progress.--The post-operative dressing one week later showed ioo per cent. take of the skin grafts. (Fig. 14 shows the condition of the legs three weeks postoperatively.) Six weeks after operation the legs were completely healed and the patient started walking. She was discharged from hospital eight weeks from the date of injury.
C o m p l i c a t i o n s . - - T h e complications following skin avulsion injuries to the~ excessive scarring w h i c h results if these w o u n d s are allowed to granulanon. T h e s e complications are : - I. Limitation of Joint Movement.--When a scar is situated over a joint the contracting b a n d can be responsible for limitation o f m o v e m e n t and subluxation o f the joint. Arthritic changes can also o c c u r (Fig. 15).
are due heal by surface, produce
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SURGERY
2. (Ndema of the Limb.--Owing to deep scarring and poor lymphatic return, eedema may be observed in the limb distal to the scar. 3. Unstable Scars.--This is fairly frequently seen in these injuries. The scar is liable to ulceration and may undergo malignant degeneration. 4. Loss of Normal Contour of the Limb.--This is due to the absence of subcutaneous fat and is also seen in those cases which have been skin-grafted (Illustrative Case I, Fig. 3, and Illustrative Case 5, Fig. I4). DISCUSSION
All too often an avulsed flap is returned to its bed and sutured in the vain hope that either the whole of it or part of it will survive. This practice is to be strongly condemned. In contrast to the care, planning, and technique which go into the construction of a pedicled flap for any other routine procedure, these avulsed flaps are invariably badly based and raised in a most traumatic manner under adverse conditions. Table II shows that avulsion injuries so treated are very often heavily infected. This can be attributed to the inadequacy of the initial surgical debridement where in an anxious attempt to get primary closure, devitalised tissue is retained. Infection delays the application of skin grafts and diminishes their chance of survival. By immediate excision of the avulsed flap and the application of a split-skin graft we ensure: (a) a more radical debridement; (b) immediate closure of the wound ; (c) diminished chances of sepsis ; (d) reduced scar tissue formation. It is often forgotten that an intact skin surface provides the best barrier against infection, and it should be the aim of the surgeon to re-establish this barrier. In cases of extensive injury, Prendiville and Lewis have advocated immediate excision of the flaps and the delay of skin grafting for one week to allow natural h~emostasis to occur. Against this one must consider the risk of infection in an open wound, and particularly in the aged, the undesirability of two or may be three operations at close intervals. I have found that the bed is most suitable for grafting at the time of the initial operation, that is, at the time of excision of the flaps, and in my opinion the h~emostasis which is observed at the end of one week is that which should normally occur with the application of a pressure dressing following a skin graft. In Illustrative Case 5, an elderly woman with extensive avulsion injuries of both lower limbs, immediate excision of the flaps and skin grafting was carried out. Both legs showed sound healing at the end of six weeks and no further operation was necessary. In cases where an avulsion injury is complicated by a compound fracture, I consider it necessary to treat the avulsion injury first to provide the skin cover. Where there is no actual fracture but the cortical bone is exposed, one of two procedures may be adopted. Either the bone may be left exposed allowing it to cover over by granulation, or it may be pared to produce a freshly bleeding surface on which an epidermal skin graft may be placed in the hope rather than the belief that it will survive. Avulsion injuries of the hand may be considered in two categories : (I) dorsal avulsions and (2) palmar avulsions. Avulsed flaps of the dorsum of the hand which are distally based are better excised and skin-grafted. In dorsal avulsions an important point in the operative procedure is to apply the skin graft with the fingers in flexion ; if this is not done, the final result will be marred by limitation of flexion
SKIN
AVULSION
INJURIES
OF THE
EXTREMITIES
~33
at the metacarpo-phalangeal joints on account of shortage of skin. Palmar avulsions are also treated by excision and grafting. Injuries which are superficial to the palmar aponeurosis accept a graft very well. Some objection may be raised to the sacrifice of the specialised palmar skin and its replacement by a split-skin graft from elsewhere ; however, in the treatment of full-thickness burns of the palm where this is the recognised practice, we know that the skin grafts so applied become stable and pliable, and will stand up to heavy use. There has been a remarkable absence of post-traumatic oedema in hands treated by this method ; this can be attributed to the early institution of physiotherapy which this procedure allows, and to the absence of deep scarring. It should be noted that this line of treatment is not advocated in those cases where tendons or underlying bone is exposed. These injuries require more elaborate pedicled flaps to obtain cover. Farmer (1939) suggested that the flap should be excised at its base, the subcutaneous fat removed, and the skin replaced as a Wolfe graft. I have not attempted this method of treatment. The objection I hold to this is that a bruised and traumatised Wolfe graft is used, whereas a freshly cut split-skin graft would have a better chance of survival. Other writers have suggested that all non-viable tissue should be excised and the flap returned to its bed and sutured. I feel that one can never be certain of the circulation in these flaps and that a flap which would appear viable at the time of operation will, in forty-eight hours, show necrosis. The only way in which one can be certain that all non-viable tissue has been removed is to excise it from its base. Some other writers have advocated delay in suturing the flap for forty-eight hours in order to ascertain the blood supply, but this I feel in no way increases ,the chances of survival of the flap and merely leaves an open wound. SUMMARY Twenty cases of avulsion injuries of the extremities are presented. The treatment of this type of injury by excision of the entire avulsed flap, and where the patient's general condition permits, the application of an immediate split-skin graft, is advocated as the treatment of choice. There has been observed a remarkable absence of deep scarring and post-traumatic cedema in the limbs treated by this method. The period of in-patient treatment is reduced and the functional result is more successful. I wish to thank Mr Michael C. Oldfield and Mr Mortimer H. Shaw .for the interest and advice ~-hey have extended in the preparation of this paper. I also wish to thank Mr John Hainsworth and Miss Cecelia Campbell of the Department of Medical Photography, St James' s Hospital, Leeds, for the excellent coloured photographs.
REFERENCES ! ENTIN, M. A. (I955). Plast. reconstruct. Surg., 15,290. FARMER, A. W. (I939). Ann. Surg., ~rlo, 951.
PR~XmVlLLE,J. B., and LEwis,E. (1955). Brit. J. Surg., 42, 582. SLACK,C. C. (I952). Brit. reed. J., 2, 262.
L e f t l e g - - a v u l s i o n injury extending f r o m I in. above t h e knee joint to t h e toes. T h e injury was circumferential in its entire extent. Circulation of the limbs, however, was good. Associated c o m p o u n d fracture left tibia Right lower l i m b - a v u l s e d flap o v e r posterior aspect o f right thigh. Assod a t e d closed fracture of right tibia. Intraabdominal injuries suspected at first examination A v u l s e d flap excised. A v u l s e d flap 3 by 2½ in. over d o r s u m of the Immediate splith a n d , based d i s t a l l y [ thickness graft to at t h e level of t h e defect metacarpo-phalangeal i joints. E x t e n s o r ten- I dons n o t exposed I
R u n over by a b u s
H a n d caught in t h e wringer of a w a s h ing m a c h i n e
Case 3 . - - F e m a l e , 63 years
W o u n d toilet a n d excision of what was considered nonviable tissue carried out at an e m e r g e n c y operation on day of admission. D r e s s i n g one week later showed further necrosis of flaps. F u r t h e r excision carried out. T r a n s f e r r e d to this U n i t ten days after injury. H m m o globin 5 ° per cent. Blood transfused. Injuries of b o t h limbs skin-grafted in one operation
W o u n d toilet a n d excision o f flap carried out at local hospital. Transferred four days later to this Unit. O n e week later split-thickness skin grafts applied
Case 2 . - - M a l e , 7 years
L a r g e avulsed flap 8"by 8 in. over lateral aspect of right thigh. Flap was non-viable
K n o c k e d off a bicycle b y a heavy m o t o r vehicle. Right thigh trapped between t h e road surface a n d wheel o f the vehicle
Surgical T r e a t m e n t .
Case I . - - M a l e , 13 years
D e s c r i p t i o n of Injury.
M e c h a n i s m of Injury.
Sex a n d Age.
E i g h t weeks. Full r a n g e of m o v e m e n t . Grafts stabie. Able to do all h e r h o u s e work
Twelveweeks. Showed good healing. Grafts taken well. T h e fractures of the right a n d left tibia h a d united. R a n g e o f m o v e m e n t at left knee I8O to 90 degrees. Child h a d started to walk with sticks
Six weeks. A p p r o x i mately 90 p e r cent. take o f grafts. R e ferred back for f u r t h e r orthopmdic care
F o u r weeks. H u n d r e d per cent. take of skin graft. P h y s i o therapy started two weeks postoperatively. Discharged with good range of m o v e m e n t . P h y s i o t h e r a p y cont i n u e d as out-patient
T w e l v e weeks. Graft stable and well healed. Child taking an active part in all school sports
Final Review.
F o u r weeks. H u n d r e d p e r cent. take o f grafts. Patient discharged h o m e with full range of movement
Period of I n - p a t i e n t Treatment and Progress.
TABLE I Summaries of Cases treated by immediate Excision of the Flap and Split-skin Graft to the Defect
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R i g h t h a n d caught between two rotat'~ng steel rol]ers
R u n over by a b u s
Case 6 . - - F e m a l e ,
P u s h e d right h a n d through a window
5.--Male,
63 years
39 years
Case
4.~Male, 15 years
Case
R i g h t leg - - extensive avulsion injury ext e n d i n g from above t h e knee to t h e ankle joint and involving t h e popliteal fossa. T h e injury was circumferential in its entire extent L e f t l e g - - a v u l s i o n injury involving the lower two - thirds, also circumferential in its entire extent. N o injury to bones or m a i n blood-vessels in spite of the extent of the iniury
A v u l s e d flap of palmar skin size 3 by 3 in., distally based at t h e level of the m e t a carpal joints. The d e p t h of the skin loss is superficial to t h e t e n d o n s w h i c h were n o t e x p o s e d . Fracture of the shaft of the f o u r t h metacarpal ; no displacement of fragments. Absence of nerve a n d t e n d o n injury
A v u l s e d flap over flexor aspect of distal third o f forearm, size 3 by z½ in. Ulnar and m e d i a n nerves intact. Palmaris longus tendon exposed
All avulsed flaps a n d undermined tissue excised. N i n e t y per cent. of t h e area grafted at initial operation. Further grafting three weeks later to expedite healing of r e m a i n i n g areas
A v u l s e d flap excised. Split-skin graft to defect. T w e n t y - f i v e per cent. loss o f graft necessitated f u r t h e r grafting eight days after p r i m a r y operation
A v u l s e d flap excised. Palmaris longus tend o n also excised a n d i m m e d i a t e split-skin graft applied to t h e defect
Eight weeks. All grafts took Ioo p e r cent. Complete healing in six weeks
Five weeks. Successful take o f s u b sequent graft. Physiotherapy started three weeks after p r i m a r y operation. Discharge delayed on account of slow initial response to physiotherapy
T w o weeks. H u n d r e d per cent. take of skin graft. P h y s i o therapy started two weeks postoperatively. Discharged w i t h good range of movement. Physiotherapy continued
Twelve weeks. Walking without difficulty. Loss of n o r m a l contour o f limbs
T w e l v e weeks. Skin graft soft, pliable, a n d freely mobile over deeper tissues. H a s approximately 9o degrees flexion at metacarpophalangeal joint a n d 45 degrees at interphalangeal joints. R e m a r k a b l e absence of oedema of h a n d s a n d fingers
E i g h t weeks. Full range o f m o v e m e n t . Grafts stable a n d wound remained healed
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H a n d c r u s h e d by a falling brick w a l l Details of accident n o t available
H a n d caught between steel rollers of a cloth milling machine
Case 7 . - - F e m a l e ,
Case
R i g h t foot r u n over by t h e wheel o f a m o t o r car
Case I o . - - F e m a l e ,
16 years
H a n d caught between the steel rollers of a p r i n t i n g press
9.--Male, 53 years
Case
8.--Male, 44 years
58 years
M e c h a n i s m of I n j u r y
Sex a n d Age.
A v u l s e d flap based distally over the d o r s u m o f right foot. Size 2 by 3 in.
A v u l s e d flap over dors u m of right h a n d ; laceration across the distal palmar crease ; t e n d o n s were n o t exposed. N o associated nerve or bone injury.
A v u l s e d flap right h a n d baseddistally, involving entire p a l m a n d thumb. The thenar muscles were severed. Capsule o f m e t a carpo - phalangeal joint disorganised a n d joint cavity exposed. T h e t e n d o n s were n o t exposed. No associated t e n d o n or nerve injury
A v u l s e d flap 6 by 2 in. c o m m e n c i n g on t h e distal third flexor aspect o f right forearm, extending across t h e radial border of the forearm, based on t h e d o r s u m of t h e h a n d distal to t h e wrist joint. Associated Colles' fracture. No displacement. Radial nerve a n d artery severed in t h e region of t h e anatomical snuff-box
D e s c r i p t i o n o f Injury.
I m m e d i a t e excision of t h e flap a n d splitskin graft to t h e defect
A v u l s e d dorsal flap excised at its distal attachment. Splitskin graft applied to defect
Joint capsule of first metacarpo - phalangeal joint r e p a i r e d ; entire flap excised. Split-skin graft applied to t h e defect
Excision of flap a n d i m m e d i a t e split-skin graft after careful d e b r i d e m e n t of t h e w o u n d . T h e severed ends of t h e radial n e r v e could n o t be isolated for repair
Surgical T r e a t m e n t .
TABLE I--continued
T h r e e weeks. C o m plete take of sldn graft
T h r e e weeks. Full take of skin graft. Physiotherapy started two weeks post-operatively
F o u r weeks. Full take of grafts. Ninety-five per cent. take o f grafts. A p p r o x i m a t e l y ½ in. square of loss over thenar eminence required grafting at first dressing. Physiotherapy started two weeks post-operatively
F o u r weeks. N i n e t y five per cent. take o f graft. Discharged. P h y s i o t h e r a p y cont i n u e d as out-patient
Period of I n - p a t i e n t Treatment and Progress.
Six m o n t h s . Sound healing. Able to walk without difficulty
T h r e e m o n t h s . Graft stable a n d pliable. C a n m a k e a full fist a n d r e t u r n to full e m p l o y m e n t , working on t h e same machine
Six m o n t h s . Grafts stable and pliable. A p p r o x i m a t e l y full range of m o v e m e n t in all fingers. Is able to write with this h a n d
Twelve weeks. Full r a n g e of finger a n d wrist m o v e m e n t , i Graft stable. H o w - : ever there is a loss of t h e n o r m a l cont o u r of t h e h a n d at t h e site of injury owing to the absence 1 of subluxafion tissue
Final Review.
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Review three months later. Area had r e m a i n e d healed. Grafts stable. Full range of movement at the knee joint. (Edema of the leg below the grafted area noted at time of discharge was absent
Grafts healed. Stable. No residualdisability
Ten weeks. Grafts took Ioo per cent. D i s c h a r g e d five weeks after skingrafting. (Edema of the foot and ankle noticed at time of discharge. Physiotherapy continued as out-patient
Flap resutured to its ~ Four months. The wound was heavily bed. Transferred contaminated with twelve days later. Ps. pyocyaneus. This Examination showed delayed grafting for necrosis of the entire three weeks. Grafts flap w h i c h was applied three weeks heavily infected. later which took Flap excised. Splitwell. In-patient skin grafts applied treatment was prothree weeks later longed by poor general condition, the patient developing a pleural effusion during this time Eight weeks. Full take of skin graft. Walking without discomfort at time of discharge
Flap returned to its bed and sutured, later necrosed, and was excised. Transferred four weeks after injury. The granulating area was excised down to a fresh bed and splitskin grafts applied
Avulsed flap size 8 by 6 in. over the lateral aspect of the left leg and heel. Associated fracture mid-shaft of fibula
Avulsed flap extending from the lower third posterior aspect of right thigh across the popliteal fossa to junction of the upper and mid-third of the calf. No associated bony injury
Avulsed flap 2 in. diameter over lateral aspect of foot
L e f t leg c r u s h e d between the wheel of a heavy motor vehicle and a brick wall
Knocked down by a heavy motor vehicle
Right foot trapped between the curb and the wheel of a motor cycle
Case I.--Female, 36 years
Case a.--Female, 76 years
Case 3.--Male, 42 years
Flap resutured to its bed, later necrosed. Seen three weeks later at this Unit. Granulating area 2 in. diameter. This was excised and grafted one week later
Review four months later showed stable and pliable grafts. (Edema of the foot and ankle had subsided. Was walking well without any disability
Period of In-patient Treatment and Progress.
Surgical Treatment.
Description of Injury.
Mechanism of Injury.
Sex and Age.
Final Review.
Summaries of Cases where Necrosis of the Flap Resulted following Suture of the Flap to its Bed
TABLE II
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Six m o n t h s . No residual deformity. Grafted area remained healed s i x weeks post-operatively
Six months. Area well healed. Child walking well. May require further grafting as growth of the limb takes place
Three months. Prognosis poor. There is a hope that at a later date pollicisation of the middle finger can be attempted
Seven weeks. Successful take of graft. Discharged four weeks after admission to Unit
Eight weeks. Grafts took IOO per cent., subsequent grafting unnecessary
Flap sutured to its bed, later necrosed, and was excised. Transferred to this Unit three weeks after receipt of injury. Granulating area excised down to a fresh bed. Split-skin graft applied Flap returned to its bed and sutured. Necrosis of the flap appeared two weeks later. Transferred to this Unit. Necrosed flap excised ; grafted one week later
]-shaped flap extending from I in. above the knee to the level of the ankle joint, situated over the anterior aspect of the left leg, flap based medially. There was an associated fracture of the left fibula
Extensive avulsion in- Poor general condition Twelve weeks. Grafted areas healed well but delayed surgery for jury involving both the mdema of the four weeks. Splitpalmar and dorsal index and middle skin grafts applied aspects of left hand. fingers remained six weeks after reThe capsule of the first metacarpoceipt of injury phalangeal joint was disorganised, joint cavity exposed. Skin flaps were returned to their bed and sutured. Cyanosis of the ring and little fingers necessitated amputation of these digits three days later, followed by amputation of the thumb and necrosed flaps one week later. Transferred to this Unit at this stage. Examination showed marked 0edema of the remaining digits, i.e., index and middle, and an extensive granulating area of the palm and dorsum of the hand. Area heavily infected
Run over by a heavy motor vehicle
Run over by a heavy motor vehide
Case 6.--Female, 2 years
Case 7 . - - M a l e , 2 years
i
Inverted V-shaped flap over the upper onethird of the anterior aspect of the left thigh, size 3 by 3 in., based distally
Injury sustained when tobogganing
Six m o n t h s . No residual disability. Grafted area remained healed
Case 5 . - - M a l e , 11 years
Eleven weeks. Skingrafting delayed for t h r e e w e e k s on account of wound infection. Initial grafts took 5° per cent., subsequent grafting successful
Final Review.
V-shaped flap 2 by 2 in. right leg, based distally. V-shaped flap 2 by 3 in. left leg, based laterally. No associated bony injury
I Avulsed flaps sutured I to their bed. TransI ferred to this Unit i one week later when necrosis set in. Flaps excised and skin i grafted after three weeks and further grafting two weeks later i
Period of In-patient Treatment and Progress.
cellar
Surgical Treatment.
escription of Injury.
Fell down steps
Mechanism of Injury.
Case 4.--Female, 64 years
Sex and Age.
TABLE I I - - c o n t i n u e d
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Fell out of a m o t o r car a n d was r u n over
R u n over b y a heavy m o t o r vehicle
Case 8 . - - F e m a l e , 49 years
Case 9,--Male, 4 years
T h e scar was excised and the defect covered by split-skin grafts
L a r g e a v u l s e d flap T h e area of h y p e r trophic scar over t h e based laterally over d o r s u m of the foot the lower half of ana n d leg was excised. terior aspect of right The defect was leg a n d d o r s u m o f covered by a splitright foot. Size 9 by skin graft. A 3 in. Flap was ret e n o t o m y was also t u r n e d to its b e d a n d p e r f o r m e d to correct sutured. Necrosis of the dorsal s u b l u x a t h e flap occurred a n d the resulting w o u n d tion of the great toe healed by granulation in three months. Referred to this U n i t after one year. T h e r e was m a r k e d hypertrophic, scarring of t h e d o r s u m of the foot a n d lower o n e - t h i r d of t h e right leg. T h e r e was a dorsal sublmxation of the great toe (Fig. I5). Plantar flexion of the a n k l e i o i n t w a s limited by I5 degrees
Extensive avulsion iniury to left leg involving the entire medial aspect. The flap was r e t u r n e d to its bed and sutured, later necrosed, and t h e resulting w o u n d was allowed to heal by granulation, taking five m o n t h s for c o m p l e t e h e a l i n g . Referred to this U n i t two years later c o m plaining of swelling of the left foot a n d discomfort due to tightness in the region of t h e scar. T h e scar itself was p a p e r - t h i n in places and subject to ulceration F o u r weeks. Followi n g excision o f t h e hypertrophic scar the area was well healed and the ~,patient was discharged
T h r e e weeks. Grafts took IOO per cent. W a s able to walk w i t h o u t difficulty at time of discharge
T h r e e m o n t h s . Grafts stable a n d t h e child was walking well w i t h o u t a n y disability
T h r e e m o n t h s . O~dema absent. Grafts stable. Patient walking well
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Left forearm injured while j u m p i n g off a brick wall. (Details n o t r e m e m b e r e d by patient)
Case I o . - - M a l e ,
2 7 years
M e c h a n i s m of Injury.
Sex a n d Age.
Large avulsed flap inverted V in shape situated over t h e anterior aspect o f t h e u p p e r half of t h e left forearm, size 8 b y 4 in. Flap was ret u r n e d to its b e d a n d sutured. Necrosis o f t h e flap was observed forty-eight hours later a n d was well defined in one week. T r a n s f e r r e d to this U n i t eight days after injury. E x a m i n a t i o n showed area of necrosis over anterior aspect o f a r m corres p o n d i n g in outline to t h e original flap
D e s c r i p t i o n of Injury.
TABLE
T h e necrosed flap was excised a week later a n d a split-skin graft applied
Surgical T r e a t m e n t .
II--continued
Six weeks. T h e skin graft took ioo p e r cent. T h e patient was discharged four weeks after a d m i s sion to this U n i t
Period of I n - p a t i e n t Treatment and Progress.
T h r e e m o n t h s . Grafts stable a n d healthy. F u l l m o v e m e n t in left h a n d . N o residual deformity
Final Review.
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