Degloving Research Articles

VAC (Vacuum assisted closure) Therapy with k wire fixation as management protocol in complex compound foot fractures with soft tissue defects

Many patients who sustain high energy compound fractures of lower extremities are riddled with severe contamination of wound with soft tissue loss. This results in deep infections, non unions and in few cases, amputations. We present a case series of 10 cases with compound fractures of foot with severe degloving injury and wound contamination. Treatment entailed through debridement and was with 5 litres of saline along with betadine. Fractures were fixed with K wires and wound was covered with primary VAC application. Male to female ratio was 8:2. Most of the cases were road traffic accidents. The average number of VACs applied were 2.3. 80% cases underwent split skin graft.We conclude that VAC with K wire fixation is an effective and safe treatment in compound fractures of foot with degloving injuries.

Recurrence of Minimal Change Disease Following a Motor Vehicle Trauma: An Atypical Cause and Review of Literature

Minimal change disease (MCD) in children has a favorable long-term prognosis, and development of end-stage renal disease is very uncommon; less than 5%. In the first case of its kind, we report a 21-year-old female with a history of MCD at the age of 6, who had late relapse subsequent to a motorcycle accident resulting in a de-gloving skin injury and intensive care unit admission. MCD was confirmed by normal light microscopy, podocyte effacement on electron microscopy and absence of any deposits on immunofluorescence 3 weeks after the incident due to critical illness. It is postulated that the skin injury is what caused the relapse of MCD.

Management of Traumatic Perineal Degloving Injury: A Case Series

Degloving injury is severe and commonly results from a huge rotational force which avulses the skin and subcutaneous tissue from its underlying fascia. This injury is associated with high morbidity and mortality if mismanaged. Perineal degloving injury commonly associated with urethral injury which can be further classified into anterior and posterior urethral injury. This study retrospectively evaluated management of traumatic perineal degloving injury compared to standard approach. A total of 3 cases of open perineal degloving injuries been identified and was managed at our centre at the year 2017. 2 cases of degloving wound of scrotum and one case of crush perineal injury with transected posterior urethral were included. We reviewed methods of management and clinical outcomes of these patients. All patients promptly underwent wound debridement and surgical repair after immediate diagnosis and resuscitation. Suprapubic insertion of catheter is crucial in managing the urethral injury. The case of crush perineal injury with transected urethral treated with operation primary urethral anastomosis, de-functioning of stoma and external fixation of pelvis. Unfortunately, this case was complicated with rupture at anastomotic urethral site after a traumatic CBD insertion during his hospitalization and he was treated conservatively with CBD. All patients did well clinically with their wounds healed well. We showed a multidisciplinary team approach consisting of colorectal surgeon, urologist, orthopaedics surgeon and plastic surgeon, together with prompt diagnosis provides the best outcome were for the treatment of open perineal degloving injury.

Posterior tension band plate osteosynthesis for unstable sacral fractures: A preliminary study

IntroductionStable reduction and rigid fixation of the sacrum and posterior ring structures are of paramount importance in the management of complex pelvic ring disruptions, Tile B and C. The major concern with the use of conventional methods, like iliosacral screws and iliolumbar fixations is the increased risk for surgical and implant-related morbidity, especially in difficult situations, such as comminuted, bilateral sacral fractures, and fractures in the dysmorphic sacrum. Although various biomechanical studies have reported the posterior trans-iliac plates to provide maximum resistance to distracting forces by the principle of tension band, the literature pertaining to this implication in clinical studies has been limited. The purpose of our study was to assess the efficacy of the trans-iliac plate in the management of unstable sacral fractures and its utility in pelvic disruptions associated with surgical site morbidity. MethodologyThe patients with unstable pelvic fractures (Tile B and C) between 2013 and 2017 were retrospectively analyzed at a trauma center. First, the anterior ring disruptions were stabilized, and then, the sacral fractures (Denis Zone 1–3) treated by posterior tension band plate osteosynthesis (3.5 mm reconstruction plate) were included. Demographic and perioperative data were assessed. The outcome variables studied were surgical morbidity, pain, loss of reduction, and union and implant-related complications. The outcomes were graded using Lindhal's (radiological) and Majeed (functional assessment) scores. ResultsThirteen patients (nine male/four female) with a median age of 42 years, had sacral fractures in Denis zones 1/2/3 (four/ten/one, respectively), resulting from Tile pelvic injury B and C were included. The pelvis in five patients was stabilized only with the posterior plate due to the anteriorly-associated surgical site morbidity (Morel-Lavallee lesions and urinary tract injuries). The mean follow-up was 21.5 ± 2.8 months. All fractures had a radiological union by 22 weeks; Lindhal's grade A in ten patients and grade B in three patients. Two out of three patients recovered from preoperative neurological involvement. Two had complained of implant prominence (BMI<19 kg/m2) and there were no implant failures. Four had excellent, six had good, and three had fair or poor functional outcomes. ConclusionThe posterior trans-iliac plate is a minimally invasive and safe procedure that can be used in a wide range of unstable sacral fractures with notably less implant failure rate. The rigid posterior construct restores the principle tension between the iliac blades and minimizes the secondary displacement of the anterior disrupted structures, thereby useful in managing ring disruptions with surgical site morbidity.

Fracking, worksite injuries, and Aeromonas infection

Hydraulic fracturing or fracking is a method of extracting natural gas from the earthusing high pressure drilling equipment and fracking fluid that contains proppant and variouschemicals. It poses health risks to workers at the drilling sites, has effects on water and airquality, and creates potential health risks for people living near the drilling sites. A 30-yearoldman with no past medical history presented as transfer from an outside hospital after anexplosion on a fracking job site. This explosion released over 6000 pounds of water that threwhim 20 feet across the rig. He had radial and ulnar fractures in his right arm and digital fractureson his right hand. He also had trauma to his left knee and right posterior thigh with a largefluctuant Morel-Lavallee lesion. On day 3 the patient developed hypotension, lethargy, andnew onset fever from a possible infection of a hematoma; he was started on norepinephrineand intubated due to a decreased mental status. Cultures from the thigh were positive forAeromonas species. Aeromonas is a Gram-negative rod that is found in many environmentsthat contain water. Studies have shown that this organism grows commonly in West Texas andNew Mexico in river beds and lakes. Healthcare providers should keep Aeromonas spp in theirdifferential list of pathogens in patients with abrasions and open injuries that occurred aroundor in a body of water.

Degloving injuries in companion animals

Degloving injuries are defined as avulsions or detachment of the skin and subcutaneous tissue from the underlying muscle and fascia secondary to a sudden shearing force applied to the skin surface. Degloving injuries are characterised by extensive trauma to the skin and subcutaneous tissues. Skin loss may occur at the time of the injury, or may be delayed, due to skin necrosis such as in physiological degloving injuries, in which tangential forces separate the mobile subcutaneous tissue from the immobile underlying fascia. It is vital to remember that dogs and cat sustaining degloving injuries will have sustained significant trauma and, therefore, a holistic approach to patient management is required to ensure intra-abdominal and intra-thoracic trauma is not overlooked. This review covers patient triage, initial wound management and longer-term options for wound closure.

Is Degloving the Best Method to Approach the Penile Corporoplasty With Yachia's Technique?

To assess functional outcomes after surgical correction of congenital and acquired penile curvatures using Yachia's technique (YT) with degloving (DG) and without degloving (WDG) of the penis. A penile deformity with angle ≥30°, difficulty in vaginal penetration, and severity of erectile dysfunction secondary to penile curvatures were the indications for a surgical treatment with YT. The preoperative characteristics of the patients, postoperative outcomes (change in angulation, palpation of sutures, penile shortening, and patient satisfaction), operative time, and hospital stay were recorded. A total of 64 patients were included in this review and divided into 2 groups: 34 in group I (YT with DG) and 30 in group II (YT-WDG). The mean operative time was 65.87 ± 21.32 minutes for group I and 48.17 ± 23.82 minutes for group II (P < .02). The mean hospital stay was 3.09 ± 0.96 and 2.87 ± 0.93 days in DG and WDG, respectively (P = .324). There were no significant differences in recurrence rates and complications (palpation of sutures: group I: 14.7% vs. group II: 13.3%; penile shortening: group I: 8.9% vs. group II: 10%). At follow-up of 20.8 months, all treated patients were able to insert the penis in the partner's vagina, were satisfied overall with sexual intercourse. The outcomes of the DG and WDG techniques were similar, even if the YT-WDG presents better results in terms of less healing and operative time.

Morel-Lavallée lesion in a ‘non-traumatic’ thigh: a diagnostic challenge!

Background: Morel-Lavallée Lesion (MLL) or Morel-Lavallée Seroma (MLS) is a posttraumatic seroma that occurs following a closed degloving injury. It is very important for trauma surgeons to be aware of this relatively rarely reported entity as early diagnosis increases the likelihood of successful management.&#x0D; Case report: We present a patient, wherein the patient had no history of trivial trauma and presented with a gradually growing swelling of left thigh, that was clinically and radiologically diagnosed as a soft tissue neoplasm, successfully managed by surgical excision and were reported to be a MLS. The clinical diagnostic dilemma was solved by the histopathologist!&#x0D; Conclusion: A differential diagnosis of MLL should be kept in mind in patients presenting with soft tissue swellings.&#x0D; Bangladesh Journal of Medical Science Vol.18(1) 2019 p.145-148

Clinical Presentation and Management of Pelvic Morel-Lavallee Injury in Obese Patients.

Introduction:Morel–Lavallee lesion (MLL) is an infrequent or underreported serious consequence of closed degloving injuries. We aimed to describe the clinical presentation and management of pelvic MLL in obese patients.Materials and Methods:A retrospective analysis was conducted for pelvic trauma patients with a diagnosis of MLL between 2010 and 2012. Patients' demographics, presentations, management, and outcomes were analyzed and compared based on the body mass index (BMI) and injury severity.Results:Of 580 patients with pelvic region injuries, 183 (31.5%) had MLL with a mean age of 30.1 ± 12.2 years. The majority (75.4%) of MLL patients had a BMI ≥30 and 44% patients had pelvic fracture. Based on the initial clinical examination, MLL was diagnosed in 84% of patients and clinically missed in 16% of patients. Nonoperative management (NOM) was performed in 93.4% of patients, while primary surgical intervention was indicated in 6.6% of patients. Failed NOM was observed in seven cases, of them five were obese. The overall mortality in MLL patients was 12.6% and the frequency of deaths was nonsignificantly higher in Grade I obese patients. Multivariate analysis showed that injury severity score (odds ratio [OR]: 1.25, 95% confidence interval [CI]: 1.05–1.50) and Glasgow coma scale (OR: 0.72, 95% CI: 0.56–0.92) were the predictors of mortality in patients with MLL irrespective of BMI.Conclusions:One-third of pelvic region injuries have MLL and three-quarter of them are obese. This significant association of obesity and MLL needs further prospective evaluation.

指尖部全周性皮膚欠損に対する組み合わせ皮弁の 1 例

指尖部全周性皮膚欠損に対する組み合わせ皮弁の 1 例

Application of free nail flap from abandoned finger for repair of finger degloving injury

目的 介绍利用废弃手指的游离指甲皮瓣修复手指套脱伤的方法。 方法 自2011年8月至2017年5月我院利用废弃手指切取游离指甲皮瓣移植修复手指套脱伤患者5例。 结果 所有指甲皮瓣均Ⅰ期存活，伤口Ⅰ期愈合，术后随访3~12个月，平均6个月，手指外形良好，功能满意，两点分辨觉6~10 mm。 结论 利用废弃手指的游离指甲皮瓣移植修复手指套脱伤，疗效满意，是急诊治疗手指套脱伤的理想方法之一。

Clinical efficacy of a narrow pedicle cross-finger flap in treatment of distal fingertip degloving injuries

Objective To investigate the application of a narrow pedicle cross-finger flap in the treatment of fingertip degloving injuries. Methods Between June 2011and May 2013, 23 patients (23 fingers) suffered from fingertip degloving injuries were treated with a narrow pedicle cross-finger flap. There were 15 males (15 fingers) and 8 females (8 fingers). Defects were caused by machine crush injury in 11 cases, girdle crush injury in 7 cases and punch press injury in 5 cases. The defects were located on the index finger in 10 cases, long finger in 2 cases, ring finger in 7 cases, and little finger in 4 cases. The flaps sized 2.6 cm × 1.9 cm to 6.5 cm × 2.2 cm. After six months, according to Zhang's curative effect satisfaction score method, the efficacy of the treatment was evaluated by five aspects of skin flap healing: flap fleeing, skin flap, flap outline, flap temperature and donor site scar. Results The island flaps were survived completely in 23 patients. After followed-up for 6 to 18 months (one case was lost to follow-up) . The color and texture of the flap were the same to the surrounding normal skin, and the finger shape was satisfactory. There was no pigmentation and contraction relapse of the injured finger. The mean values of static 2-point discrimination were (6.1±1.3) mm (range, 5-8 mm) of the flap. Conclusions The narrow pedicle cross-finger flap can be used to repair the fingertip degloving injuries with the flexible flap design and reliable blood supplement. The flap survives well and the repair area is good. Therefore, it is a good method and strongly recommended for fingertip degloving injuries repair in clinics. Key words: Cross-finger flap; Degloving injury; Microsurgery

Morel-Lavallée Lesions

The Morel-Lavallee (ML) lesion is a traumatic, closed soft tissue degloving injury. They have an inconsistent presentation, and diagnosis is often delayed. This review describes the pathophysiology of this injury, emphasizes the clinical and radiographic presentation, and highlights current management strategies. Early studies reported ML lesions occur solely over the greater trochanter, and while this remains the most common site, ML lesions can occur throughout the body. Early operative debridement should be performed, as aspiration or observation has an unacceptably high failure rate. Sclerodesis is an option in chronic ML lesions. ML wounds can be closed unless active infection is present. ML lesions are more frequently being recognized incidentally on imaging but are still under-diagnosed in trauma patients. The delay in diagnosis and unfamiliarity with treatment options can lead to poor outcomes and unnecessary complications.

Degloving Injury: Different Ways of Management

Degloving injury involves shearing of the skin from the underlying tissue due to differential gliding in response to the tangential force applied to the surface of the body leading to disruption of all the blood vessels connected to skin. The flap of degloved skin has precarious blood supply making it almost impossible for the flap to survive. We describe two cases of degloving of thigh managed differently in different settings.

Microsurgical treatment to open degloving injuries in plantar soft tissue

Objective To explore the emergency strategy of microsurgical replantation to open degloving injuries in plantar soft tissue. Methods From July, 2013 to July, 2017, 5 patients with plantar degloving injury were treated by micro-replantation, 3 of which were injuried by traffic accident and 2 caused by crashed injury. After early debridement, 4 cases received anastomosis of blood vessels, and 1 treated with Venous Autograft to get recovery of blood circulation. The avulsion flaps were sutured without tension. Results Four flaps survived after plantar replantation, and 1 developed a partial necrosis and secondery repaird with skin graft. The plantar repair made sensory function preserved in the maximum extent. All patients were followed-up for 0.5-2.0 years. The appearance, elasticity and feel of flaps was good. Conclusion Complete debridement, early recovery of blood supply and maximum preservation of plantar tissue function should be the key to successful replantation of open plantar degloving injuries. Key words: Plantar degloving injury; Replantation; Repair; Microsurgical technique

MOREL-LAVALLEE LESION (MLL): case report and literature review on diagnosis and management of post-traumatic MLL in patients with polytrauma

Morel-Lavallee lesion has become an eponym since Maurice Morel-Lavallee described the first closed degloving injury in 1853. In present days, Morel-Lavallee lesion is still a rare condition resulting from blunt shearing of soft tissues due to trauma that separates the hypodermis from underlying fascia. The cavity that is created between the separated skin with subcutaneous tissue and fascia becomes filled with blood due to injury to perforating arteries as well as necrotic tissues. Although the MLL is often seen in traumatic injuries to lower extremities, mostly secondary to MVCs, however, they are also seen on trunk and buttocks.&#x0D; The closed cavity formed between subcutaneous tissue and fascia may remain unrecognized for some time. However, often the lesion is easily identified on CT or MRI as well as US images taken as part of complex work up of trauma patient or for soft tissue swelling in patient with history of blunt trauma. With time the closed cavity becomes organized secondary to inflammatory reaction and subsequent development of granulation tissue and the fibrous pseudocapsule. And as the pseudocapsule is formed around the contents of the MLL, patients often have no specific clinical symptoms, except for swelling of the site. The contents of the MLL thus may remain unrecognized for many days or even months.

MOREL-LAVALLEE LESION (MLL): case report and literature review on diagnosis and management of post-traumatic MLL in patients with polytrauma

Morel-Lavallee lesion has become an eponym since Maurice Morel-Lavallee described the first closed degloving injury in 1853. In present days, Morel-Lavallee lesion is still a rare condition resulting from blunt shearing of soft tissues due to trauma that separates the hypodermis from underlying fascia. The cavity that is created between the separated skin with subcutaneous tissue and fascia becomes filled with blood due to injury to perforating arteries as well as necrotic tissues. Although the MLL is often seen in traumatic injuries to lower extremities, mostly secondary to MVCs, however, they are also seen on trunk and buttocks.&#x0D; The closed cavity formed between subcutaneous tissue and fascia may remain unrecognized for some time. However, often the lesion is easily identified on CT or MRI as well as US images taken as part of complex work up of trauma patient or for soft tissue swelling in patient with history of blunt trauma. With time the closed cavity becomes organized secondary to inflammatory reaction and subsequent development of granulation tissue and the fibrous pseudocapsule. And as the pseudocapsule is formed around the contents of the MLL, patients often have no specific clinical symptoms, except for swelling of the site. The contents of the MLL thus may remain unrecognized for many days or even months.

Sacral Fractures with Spondylopelvic Dissociation.

* U-type or H-type sacral fractures are a result of very high energy injuries that separate the lumbar spine and upper sacrum from the lower sacrum and pelvis. Advances in acute trauma care have resulted in an increase in the number of patients who survive this injury.* The choice of approach is dictated by several factors, including dorsal soft-tissue trauma, the need for neurological decompression, and the adequacy of sacral sagittal balance.* Complication rates following surgical treatment are high and primarily are related to the soft tissues.* This fracture pattern has a high association with polytrauma, major neurological injury (including cauda equina syndrome), and soft-tissue degloving injuries.* While nonoperative management may be appropriate for patients who are expected to be bedbound or non-weight-bearing for at least 3 months, the majority of these injuries are treated surgically with iliosacral screws and spinal constructs that anchor the pelvis to the lower lumbar spine.* Careful attention to damage-control principles, efficient surgical stabilization of the spondylopelvic injury and associated fractures, and early mobilization can lead to good functional outcomes following this potentially devastating injury.

Clinical observation of combined skin flap and abdominal flap for repair of distal finger degloving injury

Objective To compare the clinical effect and operation difficulty of the combined skin flap with reversed proper palmar digital arterial dorsal branch island flap and cross-finger flap and the abdominal flap in the treatment of distal finger degloving injury. Methods Inclusion criteria: ①Soft tissue defect far beyond the level of distal interphalangeal joints. ②The inured finger was from second to fifth. ③Single finger injury. ④ Iniury time within 8 h. Exclusive criteria: ①With tendon injury.② Multiple finger injuries. ③Followed-up time within 6 months. Between February, 2009 and September, 2016, 52 patients (52 fingers) with distal finger degloving injury were reviewed, there were 32 males and 20 females, aged from 18 to 60(36.02±11.00) years. The time from injury to operation was 2.5-8.0 (4.81±1.28) h. Affected fingers included index finger in 15 cases, middle finger in 22 cases, ring finger in 10 cases, and little finger in 5 cases. Twenty patients (20 fingers) were treated by combined skin flap with reversed digital arterial dorsal branch island flap and cross-finger flap(group combined-flap). The cubital skin was grafted onto the donor sites. Thirty-two patients (32 fingers) were treated by abdominal flap (group abdominal-flap). Results The patients were followed-up 6-25 (9.25±3.97) months. The operation time: group combined-flap was 80-130(98.46±8.34) min and group abdominal-flap was 85-125(107.84±8.63)min. There was no significant difference in two groups(P>0.05). Pedicle division time: group combined-flap was 15-24 (16.75±1.74) d and group abdominal-flap was 24-45(28.31±5.12) d. There was a significant difference in two groups(P<0.05). And the pedicle division time in group combined-flap was much shorter than in group abdominal-flap. Flap function at last follow-up, the excellent and good rate of the flap in group combined-flap and group abdominal-flap was 90.00% and 59.38%, respectively. There was a significant difference in two groups (P<0.05), and the flap function in group combined-flap was much better than in group abdominal-flap. Affected finger function at last follow-up, the excellent and good rate of the affected fingers was 95.00% and 71.88%. There was a significant difference in two groups(P<0.05), and the affected finger function in group combined-flap was much better than in group abdominal-flap. Conclusion The combined skin flap with reversed digital arterial dorsal branch island flap and cross-finger flap is a simple and high-survival-rate flap, whose texture, appearance and clinical outcome for repair of distal finger degloving injury are much better than traditional abdominal flap. Key words: Degloved injury; Finger; Dorsal branch, proper palmar digital artery; Island flap; Cross finger skin flap; Combined skin flap; Repair

Diagnostic and Treatment Strategies in Morel-Lavallee Lesions in the Spinal Column and Pelvis

The Morel-Lavallée lesion is one of the concomitant soft tissue lesions of pelvic fractures. Its role in spine fractures and its treatment in combination with osteosynthesis of pelvic or spine fractures have not yet been determined. The aim of this study was to analyse the best diagnostic and treatment options of both spine and pelvic fractures combined with Morel-Lavallée lesions (MLL). An analysis of the literature was performed via PubMed and Medline. This revealed a total of 197 studies and case reports. After analysing the literature, 19 studies/case reports met our inclusion criteria. There are several diagnostic options for MLL, including ultrasound, computed tomography or MRI. In spinal and pelvic lesions, ultrasound is capable of detecting MLL. Some authors tend to perform open debridement of the MLL, whereas others recommend percutanous treatment. Open debridement and vacuum-assisted closure are recommended in late diagnosed MLL, where primary suture of the soft tissue is impossible. Fracture fixation should be performed simultaneously to treatment of the MLL. Broad-spectrum cephalosporins combined with an aminoglycoside or piperacilline/tazobactam should be initiated. Radical debridement and drainage are recommended, especially when MLL is diagnosed late. Repeated ultrasound examinations should be performed of the surrounding soft tissue of the fracture. When MLL is diagnosed within 2 days, percutanous fracture and MLL treatment should be performed. After more than 2 days, both fracture and MLL should be treated with open debridement, open fracture fixation and primary suture if possible.