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Old 03-19-2004, 10:34   #1
Needle D
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Degloving

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.
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Old 03-19-2004, 11:53   #2
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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.
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Old 03-19-2004, 16:13   #3
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Arrow

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.

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Old 03-20-2004, 19:38   #4
Needle D
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Explanation needed

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.
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Old 03-20-2004, 19:39   #5
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Pic 2

Heres another angle.
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Old 03-20-2004, 20:03   #6
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collateral circlation should pick up once the limb is detached from the donor area.
Great pics.

Eagle
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Primum non Nocere
"I have hung out in dangerous places a lot over the years, from combat zones to biker bars, and it is the weak, the unaware, or those looking for it, that usually find trouble.

Ain't no one getting out of this world alive. All you can do is try to have some choice in the way you go. Prepare yourself (and your affairs), and when your number is up, die on your feet fighting rather than on your knees. And make the SOBs pay dearly."
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Old 03-21-2004, 15:50   #7
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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.
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Old 03-21-2004, 16:01   #8
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Basics First...

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.

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Primum non Nocere
"I have hung out in dangerous places a lot over the years, from combat zones to biker bars, and it is the weak, the unaware, or those looking for it, that usually find trouble.

Ain't no one getting out of this world alive. All you can do is try to have some choice in the way you go. Prepare yourself (and your affairs), and when your number is up, die on your feet fighting rather than on your knees. And make the SOBs pay dearly."
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Old 03-21-2004, 16:22   #9
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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.
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Old 03-29-2004, 16:15   #10
Needle D
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more pics

these are some more pics that i got without the bandages.
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Old 03-29-2004, 16:16   #11
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more pics
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Old 03-29-2004, 16:17   #12
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more
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Old 03-30-2004, 20:03   #13
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new pics

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.
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Old 03-30-2004, 20:04   #14
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another one

here
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Old 03-30-2004, 20:06   #15
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last one

here
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