Severe Avulsion Research Articles

Equestrian-associated injuries of the hand: a retrospective analysis of injury mechanisms and patterns.

Hand injuries are frequently caused by sports and are associated with long periods of inability to work and high economic health costs. After ball sports and cycling, the most common cause of hand injuries is horseback riding. Therefore, measures should be taken to prevent these risks and increase safety in sports, however data characterizing equestrian sports-associated injuries are limited. A retrospective monocentric cohort study was performed including 39 patients (mean age: 35 ± 2.6 (range 9-65) years, female 89.7% who sustained an injury to the hand while practicing equestrian sports during 2016-2021 and presented to our hand surgery center. Data analysis was performed to characterize the trauma mechanism and injury patterns by evaluating the clinical information system and conducting telephone interviews. Overall, 53.8% of the injuries occurred while leading the horse owing to traction by bridles or a lead rope on the fingers, whereas only 33.3% were caused by a fall and 12.8% by a bite injury. The majority (87.2%) of cases were injuries to the phalanges (metacarpus: 7.7%; carpus: 5.1%). Fractures were present in 51.3% of cases. The most serious injuries included avulsion amputations in 23.1% of patients (10.3% subtotal; 12.8% total amputation). Equestrian-associated injuries occur more frequently during horse handling than riding, resulting in severe avulsion amputations due to traction of the lunge or bridle, requiring complex microsurgical treatment. We recommend that appropriate protective gloves are worn for prevention of hand injuries. Additionally, the use of self-opening panic hooks with overload protection can prevent excessive traction. III.

Emergency Management Patient with Multiple Mid-Lower Face Fracture and Tissue Avulsion of 1/3 Mid Face : A Case Report

Introduction : Facial trauma can be defined as bone and or soft tissue damage in the face region. Severe facial trauma might cause life threatening and permanent damage such as vision loss, unable to speak, swallows and chews because there are many bones, blood vessels, nerves, muscles and sensory organs at the face region. The facial damage could be a facial bone fracture with severe avulsion of facial tissue so two-dimensional and three-dimensional measurement of the wound is taken to assess the size of tissue to be covered. The aim of this case report was to give an explanation regarding the emergency management patient with multiple mid-lower face fracture and tissue avulsion of 1/3 mid face. Case Report : A 46 years old male traffic accident patient came to Emergency Department Hasan Sadikin General Hospital with facial fracture and had a severe avulsion of facial tissue. He also had an active bleeding from his face and based on immediate examination the airway was not clear. The patient has been diagnosed with Le Fort I, right orbital rim inferior aspect, nasal, right zygoma and parasymphisis of mandible bone fracture and Tissue loss at upper lip, nasolabial, left nose, left buccal and Multiple lacerated wound at facial region. He was treated with tracheostomy to clear the airway continued with open reduction internal fixation at right orbital rim inferior aspect, nasal, right zygoma, bilateral maxilla bone and parasymphisis of mandible bone with wound closing using rotational and sliding loco regional flap technique. Conclusion : Emergency treatment on multiple facial fracture with severe avulsion of facial tissue must be done to prevent life threatening condition, permanent damage and also to support the secondary reconstruction. Keywords : Severe avulsion of facial tissue, Mid lower face fracture, Open reduction internal fixation, Rotational flap, Sliding loco regional flap

Spontaneous Regeneration of the Ramus-Condyle Unit Following Severe Avulsion Injury in a Child.

Spontaneous Regeneration of the Ramus-Condyle Unit Following Severe Avulsion Injury in a Child.

Direct Neurotization: Past, Present, and Future Considerations.

Direct neurotization is a method that involves direct implantation of nerve fascicles into a target tissue, that is, muscle fibers, skin, cornea, and so on, with the goal of restoring aesthetic, sensation and or functional capacity. This technique has been implemented since the early 1900s, with numerous experimental and clinical reports of success. Applications have included both sensory and motor neurotization of muscle, as well as protective sensory provision for other organs. These techniques have been used to restore corneal sensation, repair brachial plexus injuries, reestablish tongue movement and function through direct tongue neurotization, and reinnervate multiple facial muscles in patients with facial paralysis. Most recently, these methods have even been used in conjunction with acellular cadaveric nerve grafts to directly neurotize skin. Indications for direct neurotization remain limited, including those in which neural coaptation is not feasible (ie, surgical or traumatic damage to neuromuscular junction, severe avulsion injuries of the distal nerve); however, the success and wide-range application of direct neurotization shows its potential to be implemented as an adjunct treatment in contrast to views that it should solely be used as a salvage therapy. The purpose of the following review is to detail the historic and current applications of direct neurotization and describe the future areas of investigation and development of this technique.

Incidence and treatment of abductor deficiency during total hip arthroplasty using the posterior approach: repair with direct suture technique and gluteus maximus flap transfer.

The aims of this study were to assess the exposure and preservation of the abductor mechanism during primary total hip arthroplasty (THA) using the posterior approach, and to evaluate gluteus maximus transfer to restore abductor function of chronically avulsed gluteus medius and minimus. A total of 519 patients (525 hips) underwent primary THA using the posterior approach, between 2009 and 2013. The patients were reviewed preoperatively and at two and five years postoperatively. Three patients had mild acute laceration of the gluteus medius caused by retraction. A total of 54 patients had mild chronic damage to the tendon (not caused by exposure), which was repaired with sutures through drill holes in the greater trochanter. A total of 41 patients had severe damage with major avulsion of the gluteus medius and minimus muscles, which was repaired with sutures through bone and a gluteus maximus flap transfer to the greater trochanter. Abductor strength was maintained in the normal hips, but lateral hip pain progressed significantly, five years postoperatively (p < 0.0001). In the 54 patients with mild abductor tendon damage treated with simple repair, lateral hip pain also increased significantly during follow-up (p = 0.002). In the 35 patients with severe avulsion but good muscle repaired using a gluteus maximus flap transfer, abductor function was restored. The six patients with complete avulsion and poor muscle did not regain strong abductor power, but lateral hip pain decreased. The posterior approach offered excellent exposure and preservation of the abductor mechanism during primary THA. Augmentation of the repair with a gluteus maximus flap provided stable reconstruction of the abductor muscles and seemed to restore function in the hips with functioning muscles. Cite this article: Bone Joint J 2019;101-B(6 Supple B):116-122.

Venous Bridge Arterial Grafting for Thumb Replantation.

The purpose of this study is to describe a novel technique using an interposition vein graft for thumb replantation in these severe avulsion injuries. From 2002 to 2012, 8 patients underwent interposition venous bridge grafting from the dorsal radial artery at the anatomic snuffbox to the ulnar digital artery of the thumb. All patients had a traumatic thumb amputation with a severe injury to the ulnar digital artery. The technique began with bony stabilization; the radial artery at the anatomic snuffbox is exposed, vein graft harvested, and microsurgical end-to-side (proximally) and end-to-end (distally) anastomoses are carried out. The average time to the operating room was 7.4 hours and time to reperfusion was 9.5 hours. At 3.1 years of follow-up, all 8 thumbs remained viable, without any need for revision procedures. The only complication was a metacarpal shaft nonunion treated successfully with iliac crest bone grafting. At last follow-up, all patients reported no or mild pain, with an average metacarpophalangeal (MCP) range of motion of 46.5°, and intact but diminished 2-point discrimination. All patients were able to return to work full-time. Due to the challenging nature of thumb avulsion injuries and the pronated position of the thumb, novel salvage alternatives are important. We describe a technique when no proximal vessels are available, using a vein to bridge the dorsal radial artery to the ulnar digital artery of the thumb. This novel arterial reconstruction has shown promise in thumb replantation associated with severe avulsion injuries.

Significant breast injury after road traffic collision

There are many causes for uncontrolled haemorrhage in a restrained person involved in a road traffic collision requiring resuscitation and further intervention. A rare cause of significant bleeding can result from breast trauma. Breast injury as part of the spectrum of the ‘seat belt syndrome’ has been classified based on review of previously reported cases ranging from mild class I crush injuries through to severe avulsion class IV injuries. In the documented literature there are few reports of the more severe class IV injuries for which we present a case of significant bleeding into the breast with prompt endovascular intervention to arrest the haemorrhage.

Zur Schienenbehandlung bei geburtstraumatischen Läsionen des Plexus brachialis

Most cases of obstetrical brachial plexus palsies are mild traction injuries which resolve under physical therapy within several weeks or months. Severe ruptures or avulsion injuries of the plexus can lead to lifelong impairment of the upper extremities. Hence, in severe brachial plexus injuries the indications for brachial plexus reconstruction should be evaluated, early. At the age of about 3 months, the infant should be presented in a centre specialised in obstetrical brachial plexus palsies. In almost all cases intensive physical therapy is performed. In addition, many patients require splinting in order to gain function as part of the conservative therapy or for postoperative fixation. Depending on the type of splint, different demands are made on design, material and strategy of adjustment. Many different natural and synthetic materials are available for orthopaedic constructions. Because of its good adjustment options, the use of low temperature thermoplastic is steadily increasing. This contribution presents an overview of our currently used splints, new technical developments in our experience with more than 200 patients with obstetrical brachial plexus palsy. We present our experience with the most common splints for the use in fixation after birth-related brachial plexus surgery, subscapularis release, trapezius muscle transfer and functional improvement of hands with a lack of wrist extension.

Early Posttraumatic Rotationplasty After Severe Degloving and Soft Tissue Avulsion Injury: A Case Report

The case reported here describes early posttraumatic rotationplasty after severe degloving of the entire soft tissue sleeve from the left hemipelvis to the knee in an 80-year-old man who was knocked off his bicycle by a truck. During his treatment and rehabilitation, we observed severe complications (cerebrovascular accident, pneumonia, and spondylodiscitis). At the 2-year follow up, bony union of the rotationplasty osteotomy site was seen. The Enneking score was 10 points. The patient stated satisfaction with the outcome. At the last follow up, he was able to move around the house using his prosthesis and a walker and reported that he had been getting better at independent walking in the last 60 months, but for longer distances, he was still using a wheelchair.

Treatment of avulsion injury of three fingers with a compound thoracodorsal artery perforator flap including serratus anterior fascia

Complete degloving injury of three digits not amenable to revascularization may leave poor cosmetic and functional results. We used a compound thoracodorsal artery perforator (TDAP) flap in a 34-year-old, right-handed, male worker with traumatic degloving injury. The flap consisted of a thin nonbulky skin component isolated on two perforators in combination with serratus fascia, both pedicled on the thoracodorsal vessels. The mobility of the two flap components allowed the palmar and dorsal part of the fingers to be reconstructed without relying on multiple flaps or anastomoses. The skin component of the TDAP flap was transferred to the palmar defect, the serratus fascia flap to the dorsal part of the fingers and sutured loosely. Coverage of the serratus anterior fascia was done with split-thickness skin graft. Both components of the flap survived completely. One month after the first operation, the surgical syndactyly between middle and ring finger was separated, one month later the syndactyly between the ring and little finger. Good coverage of the soft tissue defects with good function could be achieved. There were no donor-site problems. Therefore, we consider the compound TDAP flap as a useful method that provides functional and cosmeticcoverage of severe avulsion injury of multiple digits. (c) 2009 Wiley-Liss, Inc. Microsurgery, 2009.

Acute Forearm Compartment Syndrome Secondary to Digit Avulsion Injury

Patients with mutilating hand and finger injuries often present first to orthopaedic, plastic, or general surgeons covering emergency room call and sometimes present only by telephone consultation. The present report describes a patient who presented with a severe finger avulsion in whom the most urgent issue was an ipsilateral forearm compartment syndrome secondary to the avulsion. The patient was informed that data concerning the case would be submitted for publication, and he consented. A fifty-five-year-old man was using a high-speed rotary tool, which caught a nylon cord that became wrapped around the right, dominant index finger. He presented to the emergency room with an open dislocation of the proximal interphalangeal joint. The soft tissues were nearly circumferentially avulsed (Fig. 1). Distally, the finger was dusky and insensate. The remaining fingers had normal color and capillary refill. The patient was otherwise healthy and denied taking any regular medications, including Coumadin (warfarin) and anti-inflammatory medications. Fig. 1 Near circumferential degloving injury of the index finger. The patient complained of severe and worsening pain in the forearm and required 8 mg of intravenous hydromorphone in one hour. Physical examination revealed tense swelling and tenderness, which was greatest at the volar aspect of the middle part of the forearm and was worse with passive extension of the uninjured digits. He also complained of numbness in the median and ulnar nerve distributions, where he had corresponding decreased sensibility on examination. Radial and ulnar pulses were palpable at the wrist. Radiographs of the hand reflected dislocation of the proximal interphalangeal joint of the …

Tunica vaginalis hydrocele of reposited testis

Tunica vaginalis hydrocele (TVH) is a relatively common entity. The procedure of testicular reposition in a subcutaneous pouch following severe scrotal avulsion injury is also a standard line of care. Though, the occurrence of TVH in such a reposited testis is extremely rare clinical presentation. We herein report a case of 55-year male patient who presented with swelling over medial aspect of left upper thigh which was diagnosed as TVH of reposited testis on detailed assessment. The patient was managed on the usual lines of management protocols of TVH with successful outcome.

Repair of severe avulsion injuries in lower limbs caused by traffic accidents

目的 探讨交通伤所致下肢严重皮肤撕脱伤的手术治疗方法.方法 对2000年12月～2005年6月因交通伤所致的下肢严重皮肤撕脱伤68例患者的治疗进行回顾性分析.治疗方法采用彻底清创后行骨折固定、血管神经修复,用四种处理方法行创面皮肤覆盖.原位缝合8例(外院处理后转入患者);急诊植皮或皮瓣移植修复38例,其中皮瓣修复26例,返削植皮12例;延迟一期修复15例,即急诊清创后观察3～7 d,再进行第二次清创,采用植皮或皮瓣修复创面;二期处理7例中有3例采用游离股前外侧皮瓣移植,2例采用肌皮瓣转位并植皮,2例返削植皮,对因一期处理不当致皮肤坏死或形成皮下囊肿患者采用再次返削植皮.结果 原位缝合中1例大部分皮肤成活,7例大面积皮肤坏死.急诊皮瓣完全成活26例,1例边缘部分坏死,其中皮瓣结合皮片移植9例均完全成活,急诊返削植皮12例中10例一期成活,有2例皮片部分坏死.延迟一期修复植皮除1例部分失活,其余皮瓣完全成活.二期处理中皮瓣及植皮均成活.本组患者随访6个月～5年(平均18个月),皮肤创面均完全覆盖,肢体功能恢复:优38例,良23例,差7例,优良率为89.7%.结论 准确判断皮肤撕脱伤所累及组织的伤情、安排周密的术前计划、合理选用创面修复方法是确保皮肤撕脱伤肢体功能获得最大程度恢复的关键。

Avulsion Injuries of the Nail Bed Do Not Need Nail Bed Graft

From 1985 to 1992, 12 cases of severe avulsion injuries of the nail bed were treated by allowing the nail bed to regenerate naturally, without a nail bed graft irrespective of the extent of nail bed loss. This involved simply covering the residual nail bed with the nail splint for a period of approximately 6 weeks or until the nail bed was observed to be fully regenerated. The patients were then followed up until full nail growth. It was observed that the nail bed regenerated spontaneously, followed by a normal nail growth identical to the contralateral uninjured nail.Proper coverage of the nail bed protected the culture milieu conducive to natural nail bed regeneration, and nail bed grafting was not necessary irrespective of the extent of tissue loss.

Displacement of accessory nerves to repair severe avulsion of suprascapular nerves

目的 探讨臂丛神经损伤肩胛上神经严重撕脱常规锁骨上前入路术式难以修复肩胛上神经时,后入路副神经移位修复肩胛上神经的疗效.方法 2003年2～10月对6例臂丛严重撕脱患者应用后入路副神经移位术式修复肩胛上神经,并观察肩胛冈上缘水平副神经与肩胛上神经的关系、术后斜方肌各部分肌力的变化及肩关节功能的恢复情况.结果 6例患者均顺利完成后入路副神经移位修复肩胛上神经.在肩胛冈上缘水平,副神经走行于斜方肌深面、筋膜下,定位于肩胛冈与肩胛骨内侧缘相交附近,肩胛上神经位于肩胛横韧带深侧肩胛切迹内,二者位置相对固定,相距3.5～5.5 cm,在肩胛冈上缘横切口内二者在无张力情况下直接拉拢端端吻接;术后随访18～26个月对斜方肌上部功能无明显影响,肩外展恢复35°～55°.结论 当臂丛损伤肩胛上神经撕脱严重常规手术难以解剖、进行修复时,后入路副神经移位术式是一种很好的选择。

The pulp ring avulsion lesion as a new indication for the free dorsal middle phalangeal finger flap: A case report

An ideal reconstruction of fingertip injuries should provide good sensibility and no pain in the activities of daily life. We report a case of a professional trumpet player who sustained a severe avulsion injury when his right index finger was crushed in a slamming door. The soft tissue of the distal finger was debrided circumferentially. To cover the defect we performed a free dorsal middle phalangeal finger flap from the ipsilateral ring finger. This flap provides excellent sensory recovery and an aesthetic outcome. (J Hand Surg 2003;28A:460-463. Copyright © 2003 by the American Society for Surgery of the Hand.)

Adipofascial Turn-over Flap Based on Perforators of the Dorsalis Pedis for Resurfacing Forefoot Defects: An Anatomic and Clinical Approach

The aim of this study is to stress the possibility of harvesting a more sizable adipofascial turn-over flap based on the perforators of the dorsalis pedis artery than previously described. This flap can resurface the most distal dorsal defects of the forefoot, and the posttraumatic distal amputation of the forefoot, as a new indication. A detailed anatomic dissection of the flap was carried out on 12 fresh lower extremities together with injection study to determine flap pedicle location, flap dimensions, and its area of reach in the distal forefoot. The anatomic findings encouraged the author to elevate an adipofascial turn-over flap based on the perforators of the dorsalis pedis artery, where the largest flap size was 13 x 7 cm, and the base area to flap area ratio ranged from 1:3.5 to 1:6.5. An experience with 11 flaps was quite successful on eight patients with severe crushing and avulsion injuries of the forefoot and on three patients with unstable and ulcerating distal grafted amputated stumps secondary to trauma.

Free expanded scalp flap for reconstruction of the temporal hair line

A 20-year-old male who sustained a severe avulsion injury of his left scalp and face together with a cranial bone fracture on his right temple six years previously, presented with extensive alopecia over the left temporal scalp. There was also a depression in the right temple with complex scarring caused by previous operations. A simultaneous complete reconstruction of the scalp defect and the depression was obtained by expansion of the left temporoparietal scalp, followed by free-flap transfer of the expanded tissue and augmentation with a free scapular flap. The end result was very satisfactory.

Spontaneous regeneration of the mandible in a child a sequel to partial avulsion as a result of a war injury

A 7-year-old child sustained a severe avulsion injury to the left mandible leaving a 6 cm. gap. A Kirschner wire alone was used for immobilization and stabilization. Radiographs of the mandible 2 1/2 years later showed complete osteogenesis and solid bone formation over the Kirschner wire. The young age of the patient was definitely important in influencing this favourable result. The author's experience in older war injuries patients, using the same procedure, has shown no such bone formation. The source of osteogenesis is believed to be from mesenchymal cells of the soft tissue remaining in the gap. The theories pertaining to the source and mode of osteogenesis in this case are discussed.

A gracilis myocutaneous flap for reconstruction of the scrotum

A gracilis myocutaneous flap was used in a case of severe avulsion of the scrotum and loss of both testicles. The flap was transposed and inset in such a way as to simulate a scrotum of the right volume, shape and texture: the operation gave the patient good psychological support and a very good aesthetic repair of this mutilating injury.