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Needle D
03-19-2004, 10:34
Pt got his hand too close to the paper rollers he was working on. Lucky for our pt the girl working with him was quick to get to the kill switch. The hand was not pulled into the rollers so there is no crush injury to worry about. However, the skin from the thumb and lateral index finger all the way down to the palm of the hand was ripped from the bone and pulled into the machine. So...

What do you do for initial tx?

What are the key points for treating a degloving?

And from the Docs around here what are some ideas for definitive tx for this injury?

I have the pics of the hand post op that I will post after the thread gets rolling.

Surgicalcric
03-19-2004, 11:53
Clarification needed on something. Was only the skin removed or was skin as well as muscle removed? You stated skin down to the bone which would lead me to believe all but ligaments were removed from thumb and finger, unless I am just reading it wrong.

Now for Tx:

Moist dressings and splint as necessary,

IV with MS for pain,

and transport to bright lights and cold steel.

If you can retrieve the removed skin/other tissue do so. Place in ziploc bag on ice and transport with PT to the ED.

____________
Degloving is caused by shearing forces that separate tissue planes, rupturing their vascular interconnections and causing tissue death. This most frequently occurs between the subcutaneous fat and deep fascia. They can present themselves as open or closed and can also be either localized or circumferential.

The danger of degloving or avulsion injuries is that there is devascularisation of tissue and skin necrosis may become slowly apparent in the following few days. Even tissue that initially demonstrates venous bleeding may subsequently undergo necrosis if the circulation is insufficient. Treatment of such injuries is to identify the area of unperfused skin and to remove the skin, defat it and reapply it as a skin graft in part or in whole.

Eagle5US
03-19-2004, 16:13
Treated 2 deglovings in Bosnia, similiar descriptions certainly, both treated with fine mesh dry gauze, IV NARCS, and transport via Helo.
Degloved "meat" transported with both victims, each time successful reattachment at Laundstuhl Hand clinic. LEECH therapy was utilized in both cases to promote distal circulation and induce collateral blood flow.

Eagle

Needle D
03-20-2004, 19:38
Here are the post op pics of the hand. The docs sewed the hand to the thigh with the thumb in a tube of skin. The way I understand it is after a while they will take the skin and use that as a skin graft.

My question is how does the new skin continue to recieve blood after it is separated from the leg? It would seem to me that the capillaries in the skin would be severed therefore no oxygen to the tissue.

Needle D
03-20-2004, 19:39
Heres another angle.

Eagle5US
03-20-2004, 20:03
collateral circlation should pick up once the limb is detached from the donor area.
Great pics.

Eagle

myclearcreek
03-21-2004, 15:50
A young man here recently had a wreck (street racing), in which one leg was degloved (to the bone, nothing left attached) from lower calf to ankle. This was the worst of numerous injuries, including broken clavicle, several broken ribs, and others from facial impact to windshield.

For my curiosity, what would be the order of treatment at the scene?

My apologies if this should be posted elsewhere.

Eagle5US
03-21-2004, 16:01
Airway, Breathing, Circulation...
Aiway and Breathing would both be closely addressed from your relay on the face to windshield impact...ribs can cause breathing problems...also to be repeatedly assessed...
If the leg had significant bleeding associated with it, it would probably be addressed in the "Circulation" part on the first survey through...
Bulky dressings, tourniquet placement on the distal femur, and compression of the bulky dressing with 3in ACE wraps or even an air splint if available...from your description, it would sound like an ampy was close at hand once the hospital was reached.
Primary concerns, and primary survey first...ugly things are ugly, Primary things can kill you quicker than ugly.

Eagle

myclearcreek
03-21-2004, 16:22
Thank you.

Amazingly, they reattached everything, rebuilt his ankle, and he is expected to walk freely, but unsure how much more he will be able to do.

Needle D
03-29-2004, 16:15
these are some more pics that i got without the bandages.

Needle D
03-29-2004, 16:16
more pics

Needle D
03-29-2004, 16:17
more

Needle D
03-30-2004, 20:03
last week the docs went in and detatched the thumb from the leg. The thumb has been bandaged for the entire week with no dressing changes. Yesterday a strong odor was noticed coming from the bandage. (I'm guessing it was pseudomonas) He was taken back to the hospital for re-evaluation. These pics were taken today.

Needle D
03-30-2004, 20:04
here

Needle D
03-30-2004, 20:06
here

Surgicalcric
03-30-2004, 20:11
That does not look good at all.

What was the outcome of the visit?

NeedleD, check your PM's

NousDefionsDoc
03-30-2004, 20:21
Good questions Crip. I'd also like to hear the thought process behind the no dressing changes.

Eagle5US
03-30-2004, 20:35
not looking too good indeed...may be something as simple as a congested hematoma...leech therapy may be of benefit. Any odor is a bad thing, no dressing changes was not a good idea at all.
If he isn't careful, he is gonna lose what little he has left there.
Thanks for the updates....
Eagle

DoctorDoom
03-31-2004, 18:56
x

Needle D
03-31-2004, 19:47
After another trip to the hospital, the wound still smells. The doc has changed the orders from "Do not change the dressing till you come back in two weeks." to change q24 and wash with hydrogen peroxide.

thanks for all the advice on this. Other than being able to tell good or bad I dont have any experience with this type of injury. What do you think that the pt should ask or tell the doc the next time he sees him?

Thanks

Needle D

Surgicalcric
03-31-2004, 20:05
1.)Why the hell he ordered the bandage not be changed for two weeks. Dirty bandages are a breeding ground for all types of bad ju-ju. I have had quite a few sutures and I have always changed mine daily.

2.)Why no leach therapy?

3.)Why the two week wait between visits? Seems to me with that serious an injury the first few visits would have been closer.

Was the patient on any oral Abx? If so what were they?

Hope your friend gets better, but that thumb dont look good.

myclearcreek
03-31-2004, 20:33
My sister-in-law lost her little finger, they reattached, then amputated after a few weeks. Her finger looked better than the pics of this one.

DoctorDoom
04-01-2004, 03:32
x

Needle D
04-07-2004, 17:32
Sorry it took so long to get this information. The surgery was done by an Orthopedic surgeon (Im not quite sure why) and he has been on keflex since the injury. When he went to he hospital all they did was switch him to IV instead of PO.

More pics comming soon

Needle D
04-11-2004, 18:08
new pics of the thumb

Needle D
04-11-2004, 18:10
pic

Needle D
04-11-2004, 18:11
here

Surgicalcric
04-11-2004, 18:40
Well, that looks much better than it did on the last update.

I am still curious as to why he was told not to change the bandages for 2 weeks...

DoctorDoom
04-11-2004, 20:35
x

Needle D
04-11-2004, 22:21
I couldnt understand why ortho either. To his knoledge there is only one doc that has worked on him. Although we dont know who went in to the OR.
Any ideas on why he was told two weeks? I have heard of a guy named Coupland who did alot of work on the afgan border after the war with the soviets who was leaving amputations for 5 days with no dressing change. He was said to have good results with it. Infact SOMTB is teaching it as a care plan.

Surgicalcric
04-11-2004, 22:31
They are teaching 5 days or 2 weeks?

DoctorDoom
04-11-2004, 22:52
x