Degloving injury: Report of three cases and review of

the literature

A.V.Kyriakidis , D.Antoniou, A.Zacharopoulos

Departments of Surgery and Orthopaedic Surgery, General

Hospital of Amfissa

Corresponding author:
Kyriakidis Alexandros
Frouriou 95, 33100.
Amfissa.
Tel.number:22650-72265.
Fax number: 22650-22086.
E-mail:alkidi@hotmail.com
Abstract

Background/Aims: Degloving is a potentially serious injury in which an

extensive area of skin is torn from its underlying attachments and thereby
deprived if its blood supply. Methods: Three cases of degloving injury are
described, two occurring as a result from the shearing effect of a vehicle
wheel passing over the limb in a run-over accident and one caused by a ring
of the fourth hand finger. Results: The degloved skin must be either grafted
with the help of plastic surgery or treated conservatively with the use of
dressing application. Conclusion: Degloved skin is dead and should be
replaced as if it were a free skin graft. A number of plastic surgical procedures
are available at the moment.

Key words

Degloving trauma, tissue injury, skin, plastic surgery

Introduction

Degloving injuries cause stripping of skin and underlying tissues from the
bones, usually of the hands or feet as occurs in run-over accidents, wringer or
industrial roller injuries. [3, 22, 46, 48] These three cases of degloving injury of the
lower limb and the fourth finger of the right hand respectively are presented in
order to describe this rare and potentially very serious injury of soft tissue.

Case reports

Case 1. The patient is a 65-year-old-male who had a high speed road

accident with his motorbike. He sustained a diaphyseal fracture of his right
femur, an open (grade I) fracture of his right distal radius and ulna as well as a
large degloving injury of his right thigh, extending from the perineum to the
greater trochanter and to the middle of the anterior surface of his thigh. The
broken thigh is shorter and fatter than normal and lies with the distal fragment
in external rotation. There is edema and erythema all over the middle third of
the right thigh and a large degloving injury (skin peeled back over the
quadriceps muscle) extends from the perineal region medially, to the greater
trochanter laterally and to the middle of the anterior surface of the thigh. There
is no active bleeding in the degloving area. No active movement is possible in
the knee and the hip joint and no passive movement allowed by the patient
due to the extreme amount of pain. Reguarding the patient’s right upper
extremity, there is an open fracture of the distal radius and ulna. No active
bleeding present at the time of arrival from the fracture wound. There is
neither active, nor passive movement of the right wrist joint. The patient was
immediately prepared for an emergent surgery. After receiving general
anesthesia the following procedures took place in the operating theatre: a)
debridement of the wound injury removing the subcutaneous fat from the
damaged skin and applying it as a free graft b) Initial stabilization of the
femoral fracture with external fixation c) Surgical cleaning, closed reduction
and stabilization of the right forearm fracture with external fixation. During our
routine 2-month clinical follow-up, the patient showed no signs of infection, no
skin necrosis at the degloving injury site, while the fractures of the right lower
limb and the patient returned to ambulation with the use of a cane.
Case 2. The patient is a 63-year-old female, who had a road accident. The
patient had fractures in the bodies and spinous processes of the C6 and C7
cervical vertebrae, hematomas of the left scapular region and the left temporal
region of the scalp, as well as an extensive(20cm X 20cm) degloving injury
(cutis and sub-cutis) of the left tibia. The patient was brought to the
Emergency Department of our hospital, where she was initially evaluated for
her cranial and cervical injuries. A simple, but not closing suture (5-hours
after) was performed in her left tibial open wound. When the patient was
stabilized (after a 3-day period) the patient was transferred in our Department
of Surgery. During the degloving injury re-evaluation of her left tibia, a full-
depth dermal necrosis was noted. On the 14th post-traumatic day, the
necrosis involved the whole wound (pic.1a) and a thorough surgical
debridement was performed (pic.1b).The patient was treated conservatively,
with the use of an Alginate Dressing (SeaSorb Ag R) and a Foam Dressing
(Biatain Ibu R). In the 15th day period after the surgical debridement and the
dressing placement, granulation tissue development was noted in the whole
wound region (pic 2), in the 30th day period a full depth wound coverage and
small diminution of the wound limitations (pic 3), in the two month period the
diminution of the limitations was at its half (pic 4) and finally in the 3,5month
period almost complete wound coverage (pic.5).

Case 3. The patient is a 70-year-old-female who had a degloving injury of

the fourth finger of the right hand (ring finger). The skin and the underlying
tissues had been peeled off the underlying bone over a distance of 2.5cm.The
ring finger peripherally was edematous, erythematous and extremely
painfull.The patient noticed the lesion before 10-days period but did not want
to visit the hospital, even though during all this time the body temperature was
not below 38 degrees Centigrade. It was a very serious lesion and could not
be treated by rolling the skin back into place. Three samples of wound culture
were taken. The patient was immediately operated, the ring finger was
amputated and its skin was used to cover the defect. She was released from
our hospital after a 2-week period of hospitalization. Over a period of 2-month
clinical follow-up, the patient showed no clinical signs either of infection or of
inflammation.
Discussion

The skin is the most extended organ of the human organism. It has a
multifunctional role (excretory, protective, temperature-regulatory, and
sensory) which gives a high level of importance in case of skin injury. Skin can
be damaged in the following ways: direct trauma, stretching, degloving and
undermining during an operation. [44,5,42,45] If a limb is caught firmly and pulled
violently at the moment of impact, the skin may be peeled back over
underlying tissues, most often bones, for a considerable distance perhaps
over the whole leg or forearm. These injuries are called “degloving” injuries
but the same problems, as in degloving injuries, can arise just by stripping the
skin off the underlying tissues without being rolled back like glove (common in
fractures of the tibia and fibula). [18,36,41] In the hand or arm it is commonly
caused by the limb being crushed between rollers, while in the leg it may
result from the shearing effect of a vehicle wheel passing over the limb in a
run-over accident.Degloving tissue injuries can interrupt large vessels and the
continuity of capillary beds. [8, 11, 17] Edema soon forms’, increasing the distance
oxygen needs to diffuse from functioning capillaries. Any injured tissue swells
and must have room to expand if there is no room for expansion the tissue will
become ischaemic.This often creates a vicious circle, causing complications
such as compartment syndrome (a condition in which pressure within a
confined space results in tissue ischemia and resulting dysfunction) and frank
sloughing of compromised tissue. [1, 37, 2, 28]
The skin may remain unbroken, in which case the limb feels like a fluid-
containing bag, owing to the presence of an extensive haematoma between
the skin and the fascia (compartment syndrome). [20, 24, 14, 32]If the skin is torn,
the effect is the creation of a large flap of full-thickness skin. In either case,
massive sloughing is likely unless the injury is properly managed. [10, 7, 15]
Depending on the type of skin or tissue damage a number of plastic surgical
techniques are possible for tissue repair:

1. If the skin is in good condition it may be de-fatted and re-applied

immediately as a full thickness graft .[19,23] (although failure is not
uncommon)
2. If the skin is damaged, split skin grafts may be taken from it (prior to its
excision); these may be used immediately if the site is suitable, or
stored for a secondary procedure.
3. The flap may be marked for later orientation and excised. After
refrigeration storage in a sterile container (storage temperature is
important), it is replaced after 1-2 weeks as a single sheet graft, after
the deeper layers have been removed using special equipment.

According to Adani et al, wound coverage after a complete degloving injury of

the hand and fingers is one of the most difficult problems in hand surgery.
Important structures such as tendons, nerves, and bones are exposed and
will necrose if not covered adequately. [34, 35, 26, 6] The main problem in
degloving injuries is the extensive damage to long segments of vessels which
makes direct suture of the structures difficult. Various techniques have been
proposed over the years to bypass the segment of an injured vessel. [30, 43, 39]
Many of these are difficult and often require the execution of several vascular
anastomoses. The transfer of vessels from adjacent fingers is a valid
alternative. Revascularization of the degloved skin does represent the best
solution and must be managed as an emergency procedure. Coverage
obtained in this way offers the best cosmetic result and allows early
mobilization with good recovery of joint movement. [33, 12, 13]In some cases
however, according to Takeuchi et al, complete degloving injury of the digits
not amenable to revascularization may leave poor cosmetic and functional
results. [21, 27]
Re-establishing sensibility is even more difficult. It is not always possible to
suture the nerves damaged by the trauma, and even when a careful primary
nerve anastomosis is performed, the results often are unsatisfactory, probably
because of the avulsive mechanism of nerve injury. [4, 25, 40]
In regard to damaged soft tissue elements, deciding what is viable is primary.
This will guide the debridement and determine if primary closure or immediate
reconstruction is feasible. Direct observation is very useful. Skin with bleedy
edges, good colour and rapid capillary refill will most likely survive. It is
therefore recommended that rapid and thorough debridement of all non-
perfused, non-viable tissues be performed before sepsis occurs. Damaged
muscle, if exists, should be resected to prevent the sequelae of severe
myonecrosis or acute tubular necrosis. Denuded areas should be temporarily
covered with either moistened dressings, xenografts or both. Reconstructive
efforts, if needed, are guided by the condition of local tissues.
The goal of treatment should be coverage with a pliable, sensitive, and
cosmetically similar tissue that will allow early mobilization.In any open injury it
is vital to keep in mind the risks of serious, life threatening infections,
particularly tetanus and gas gangrene, and the appropriate protective
measures must be taken. [9, 16, 31, 38, 47]

Conclusions

Degloving injury is very serious and potentially dangerous soft tissue lesion. It
completely destroys normal skin and underlying soft tissue rendering the
human organism defenseless and vulnerable to soft-tissue necrosis and
consequently to numeral life-threatening infections. The presented cases
illustrate the magnitude of injury in degloving injuries to the lower extremity
and the variety of techniques that can be used in reconstruction. Treatment
depends on the time of detection and the extend of tissue injury .In early
stages and good soft-tissue condition, after de-fatting of damaged skin,
immediate re-appliance of a full thickness graft is the treatment of choice. If
delay is substantial, because of contamination and inflammation of the
surrounding tissue, advice and possible treatment from an experienced plastic
surgeon is highly desirable.
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Figure 1(Case 1.Femoral diaphyseal shaft fracture)
Figure 2(Case 2.Radial-ulnar fracture)
Figure 3(Case 1.Degloving injury operating theatre)