Avulsion dan Degloving injury

dr. M. Luthfi Prasetyo

Stase Bedah Plastik RSU Kabupaten Tangerang

Maret-April 2023
 Skin and soft
tissue injury

Degloving Avultion

Open partial

Closed Total

Chung KC, Gosain AK, Gurner GC, Mehrara BJ, Rubin JP, Spear SL. Grabb and Smith’s Plastic Surgery. 7 th ed, Philadelphia: Wolters Kluwer; 2014.
 Definition
• Avulsion – sections of skin torn off Degloving – a form of avulsion of
either in part (attached to body) or soft tissue, in which an extensive
totally (detached from body). portion of skin and subcutaneous
tissue detaches from the
underlying fascia and muscles.

Avulsion and degloving

are usually increased morbidity
underestimated and mortality!
 Etiology
Shearing force which is applied at a tangent to a
trapped limb :

”Caught in roller-type machinery”

“Trapped between the wheel of a vehicle and the road surface”

rupture of the tissue at a point distal to the site of

compression

stripping of the skin and subcutaneous tissue of the limb

through the fascial plane
 Pathology
Thick layer of subcutaneous fat and skin is ripped from its underlying fascia

Lymphatic perforating vessels are torn and release their content --> cavity

As lesion progress beyond the acute phase, blood is reabsorbed and replaced
by serosanguineous and lymphatic fluid

Infalmmation  cystic mass surrounded by fibrous capsule (peripheral

deposition of hemosiderin, granulation tissue, and fibrin)
 Type Classification

 Closed degloving : skin intact; skin and • Limited degloving with abrasion/avulsion
subcutaneous tissue is separated from the
underlying fascia, creating a cavity filled with • Non circumferential degloving
hematoma and probably liquefied fat tissue
• Circumferential single plane degloving
 Open degloving : skin continuity disrupted
• Circumferential multi plane degloving

Atmadja TM, Sudjatmiko G. Management of patient with closed degloving in the pelvic region : a case series. JPR. 2012.
Arnes ZM, Khan U, Tyler MPH. Classification of soft-tissue degloving in limb trauma. JPRAS. 2010.
 Diagnosis
• Clinical assessment of the degloved skin is a weak predictor of the extent of injury.
• Skin with bleeding edges, good color  likely good outcome.

Arnes ZM, Khan U, Tyler MPH. Classification of soft-tissue degloving in limb trauma. JPRAS. 2010.
Latifi R. The therapeutic challenges of degloving soft tissue injuries. J Emerg. Trauma Shock. 2014
 Skin vitality test

Dermal Split thickness Illumi

Fluorescein nation
capillary skin excisions
test using
bleeding (STSE) Wood’
s lamp

Lim H, Han DH, LEE IJ, Par MC. A simple strategy in avulsion flap injury : predition of flap viability using wood’s lamp illumintaion and resurfacing with a fill-thickness skin
graft. Arch Plast Surg. 2014.
Myerson M. Split-thickness skin excision : its use for immediate wound care in crush injuries of the foot. Foot & Ankle. 1989.
 Limited degloving with
abrasion/avulsion
• There is loss of tissue as a result of the
abrasive force. There is little
undermining of the remaining skin edges.

Arnes ZM, Khan U, Tyler MPH. Classification of soft-tissue degloving in limb trauma. JPRAS. 2010.
 Non circumferential degloving
• The majority of skin is still present either as a
flap or as an area of extensive undermining.
• The plane of avulsions is  single layer
(between deep fascia and subcutaneous)

Arnes ZM, Khan U, Tyler MPH. Classification of soft-tissue degloving in limb trauma. JPRAS. 2010.
 Circumferential single plane degloving
• Either open or closed circumferential
degloving of the integument confined to a
single plane (usually between the deep
fascia and the subcutaneous fat and skin )

Arnes ZM, Khan U, Tyler MPH. Classification of soft-tissue degloving in limb trauma. JPRAS. 2010.
 Circumferential multi plane degloving

Circumferential
multiplane
• Higher force

Arnes ZM, Khan U, Tyler MPH. Classification of soft-tissue degloving in limb trauma. JPRAS. 2010.
Closed degloving injury (RSCM)

Basic principles:
1. Make incision

2. Put drain in the

lowest area (drainage)

3. Wrap without
pressure
 Treatment Principles
• Preservation of as much tissue as possible

• Early primary definitive skin cover

Conservative
• Good-quality skin cover

• Early return of function Surgical

• Necessity of any secondary procedures.

Latifi R. The therapeutic challenges of degloving soft tissue injuries. J Emerg. Trauma Shock. 2014
Management: Conservative
• Compression dressing

• Aspiration
 Small incision

 Large incision  evacuation, debride necrotic components, capsular resection (chronic)

• Depends on characteristic
Management: Surgical
• Indications:
 Absolute indications: deep infection, sever skin necrosis, open fracture

 Relative: unsuccessful nonsurgical treatment, symptomatic lesions, and planned for surgical
approach for acute fixation of a closed fracture
Methods
• Open debridement

• Limited incision

• Sclerodesis: talc and doxycycline (most common) or alcohol, bleomycin, and

tetracycline
Post operative management
• Drain: remove  30 cc/day
• Compression
• Antibiotics: until 24 hours after drain removal
Complications
• Post operative infections
• Recurence
• Skin necrosis
• Contour deformity
Management
• Resuscitation
• Tetanus prophylaxis and antibiotic administration
• Wound irrigation and debridement
• Soft tissue coverage

Best option for soft tissue coverage?

Soft tissue coverage
 Excision and skin graft
• Majority of the literature recommends surgical excision
• The avulsed skin has been used a source of skin grafts (split or full thickness).
• Immediate use of the degloved skin as a skin graft gives the most satisfactory
coverage

Arnes ZM, Khan U, Tyler MPH. Classification of soft-tissue degloving in limb trauma. JPRAS. 2010.
Innis CO. Treatment of skin avulsion injuries of the extremities. St James’s Hospital.
 • By immediate excision of the avulsed flap and the application of a 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.

Innis CO. Treatment of skin avulsion injuries of the extremities. St James’s Hospital.
 Avulsion & Degloving
Summary

Irrigation and debridement

Vitality test

Vital Non vital

Suture without tension Excision

Adequate skin Inadequate skin

Compression

Defatting STSG

FTSG

Compression
Thank you
 References
1. Wojcicki P, Wojtkiewicz W, Drozdowski P. Severe lower extremities degloving injuriesmedical problems and treatment results. J Polski Przeglad Chirurgiczny.
2011;83(5): 276- 282.
2. Mello DF, Assef JC, Solda SC. Degloving injuries of trunk and limbs: comparison of outcomes of early versus delayed assessment by the plastic surgery team. J
Rev Col Bras Cir. 2015; 42(3): 143-8.
3. Latifi R, Hennawy HE, Thani HA. The therapeutic challenges of degloving softtissue injuries. J Emerg Trauma Shock. 2014; 7(3): 228–32.
4. Pilanci O, Saydam FA, Basaran K, Datli A, Guven E. Management of soft tissue extremity degloving injuries with fullthickness grafts obtained from the avulsed
flap. J Ulus Travma Acil Cerr Derg. 2013; 19(6): 516-20.
5. Arnez ZM, Khan U. Classification of soft-tissue degloving in limb trauma. British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by
Elsevier Inc; 2009.
6. Antoniou D, Kyriakidis A, Zaharopoulos A. Degloving injury. Eur J Trauma. 2015; 31(6): 593-596.
7. Semer NB. Skin grafts. Chapter 12. Practical Plastic Surgery for Nonsurgeons. Philadelphia: Hanley and Belfus, Inc; 2001.
8. Hakim S, Ahmed K, Menyar AE, Jabbour G, Peralta R, Nabir S, et al. Patterns and management of degloving injuries: a single national level 1 trauma center
experience. World J of Emerg Surg. 2016; 11(35): 1-8.
9. Krishnamoorty R, Karthikeyan G. Degloving injuries of the hand. Ind J Plast Surg .2011; 44(2):227-236