1. Degloving of the limb occurs in the plane superficial to the deep fascia and the extent of injury is often underestimated.
2. Thrombosis of the subcutaneous veins usually indicates the need to excise the overlying skin.
3. Circumferentially degloved skin is not viable.
4. In severe injuries, multiplanar degloving can occur with variable involvement of individual muscles, which may be stripped from the bone. Under these circumstances, a second look is usually necessary.
5. It may be appropriate to offer patients with severe multiplanar degloving over a wide zone primary amputation within 72 hours of the injury.
6. Large collections (greater than 50 ml) associated with Morel–Lavallée lesions may be best treated by surgical evacuation rather than aspiration.
Degloving is often associated with high-energy injuries. It occurs when the skin surface is subjected to forces, including torsion, crush, avulsion, or a combination of these. The soft tissues are sheared along single or multiple tissue planes, depending on the severity of the injury. In uniplanar injuries, degloving occurs between the subcutaneous fat and deep fascia. By contrast, in multiplanar injuries tissues are disrupted between and within muscle groups and between muscle and bone. Therefore, multiplanar degloving injuries represent a much more severe group. Both trans-muscular and intermuscular perforating vessels that normally perfuse the skin are avulsed during the degloving process, resulting in necrosis of the overlying skin. Necrosis of the degloved tissues may evolve over time and, whilst the underlying mechanisms remain largely unknown, venous congestion and inflammatory cell infiltrate may contribute and subjacent haematoma leads to production of proinflammatory cytokines and free radicals (1). Whilst evacuation of any haematoma may help salvage threatened skin, the mainstay of treatment remains excision of non-viable tissues and subsequent reconstruction.
Patterns of injury
The viability of the degloved tissues can be difficult to assess, and grading systems based on the degree of injury to the subcutaneous veins have been devised to help decide how best to salvage the affected tissues (2, 3). Intra- and subdermal thrombosis manifests as ‘fixed staining’. This refers to the state of the skin on clinical inspection where there is a spectrum of discolouration of the skin. The colour can vary from red to blue but fails to blanch on digital pressure. Intravenous fluorescein may delineate non-viable tissues more accurately (4) but requires specialised equipment, carries a small risk of anaphylaxis, and has poor specificity.
In the clinical setting, the most useful classification system describes four patterns of degloving (3):
1. localised degloving;
2. non-circumferential, single plane degloving;
3. single plane, circumferential degloving;
4. circumferential and multiplanar degloving.
Over bony prominences, such as malleoli and condyles, pattern 1 can be associated with soft tissue loss because the mechanism of injury that usually causes degloving in these areas can result in tissue abrasion and avulsion. Whilst patterns 2, 3, and 4 can present as closed injuries, in practice, pattern 4 usually presents as an open wound. Circumferentially degloved skin is usually not viable as it will have been stripped of the perforators upon which it survives. Multiple patterns may co-exist in some patients and multiplanar injuries can occur in the absence of circumferential degloving. Patients with a wide zone of multiplanar degloving associated with a segmental tibial fracture may be best served by a primary amputation. Under some circumstances it may be appropriate to use free tissue transfer to achieve soft tissue coverage of the residual limb to enable a trans-tibial rather than through-knee amputation or to consider using spare parts from the distal part of the limb (5).
Degloving injuries require definitive reconstructive surgery, which comprises excision of devitalised tissue and application of meshed split thickness skin graft, with flap coverage for exposed bone and fractures. The devitalised skin should be assessed clinically (as previously described) and carefully marked with a pen. The area is then excised systematically as per the approach used for wound excision (see Chapter 3). The soft tissues are assessed from superficial to deep in turn. On occasions when the soft tissue damage is difficult to assess, a second look should be undertaken 24–48 hours later when the devitalised tissues will have declared themselves. However, a general principle in open fracture management is that open fractures should be covered as soon as possible, and certainly within 72 hours. Therefore, repeated wound excisions are best avoided if possible (6).
At the end of soft tissue wound excision, conditions should be akin to those encountered during elective surgical wounds and meshed split thickness skin graft can be applied if appropriate. Skin grafting should not be performed if there is an underlying exposed fracture, which should instead be covered with a flap. Occasionally, the degloved skin can be used as a source of skin graft if it has not been traumatised directly. Some authors have reported the use of meshed split thickness autograft supplemented with overlying allograft or with an underlying dermal substitute such as Integra® (7). Full thickness skin grafting has also been described (8, 9). However, there is limited evidence to support these techniques and outcomes are likely unreliable.
We recommend the use of negative pressure wound therapy (NPWT) to secure the skin grafts (10). This offers the benefits of securing the graft to the recipient wound bed, which is often irregular, thus reducing the risk of fluid collections under the graft and maximising graft take (11, 12). A comparative study has shown that negative pressure treatment led to reduced requirement for repeated skin grafts and improved overall graft survival (12). A subsequent clinical trial found that NPWT also improved the qualitative appearance of split thickness skin grafts compared with standard dressings (13).
Closed degloving can present as post-traumatic subcutaneous fluid collections and diagnosis may be delayed several days to months following injury. Delayed diagnosis and treatment often results in full thickness necrosis due to compromised vascular supply of the avulsed skin flap. A specific type of closed degloving injury, where the subdermal fat is sheared from its underlying fascia and is associated with an effusion containing haematoma, lymphatic fluid, and necrotic fat, is known as the Morel–Lavallée lesion (14). These tend to occur in polytrauma patients and are associated with a high rate of infection, especially if there is an underlying fracture (15). Early diagnosis (by MRI) and treatment of closed degloving injuries are important to prevent infection, extensive skin necrosis, and chronic recurrence (16). Management options include aspiration and insertion of vacuum drains, or wound excision with or without sclerosing agents, followed by external compression. A retrospective study of 87 Morel–Lavallée lesions found that percutaneous aspiration had higher rates of recurrence (56%) compared with the observation and operative groups (19% and 15%, respectively) (17). Furthermore, based on their observation that aspiration of more than 50 ml of fluid is associated with a higher rate of recurrence (83% vs 33%), the authors recommended that lesions containing more than 50 ml should be managed surgically.
The standard of care for the treatment of degloved soft tissues remains excision of the devitalised tissues and reconstruction. The margin of excision can be difficult to determine. Fixed staining and thrombosis of the subcutaneous veins are indicative of skin that will not survive. Circumferentially degloved skin does not survive and the patient with multiplanar degloving should undergo meticulous and systematic excision of all the non-viable muscle and skin. A second look procedure may be necessary 24–48 hours later. Whilst large defects may be successfully reconstructed with free tissue transfer, it may be appropriate to offer patients with severe injuries a primary amputation.
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