Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 11  |  Issue : 2  |  Page : 63-67

A rare case: Avulsion amputation of the hand with degloving of the soft tissues from the level of the arm


Department of Hand and Micro-Vascular Surgery, Khoula Hospital, Muscat, Oman

Date of Web Publication10-Mar-2016

Correspondence Address:
Rahul K Patil
Department of Hand and Micro.Vascular Surgery, Khoula Hospital, Al Wuttayya, PC 116, Muscat
Oman
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0794-9316.178451

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  Abstract 

We hereby report a case of avulsion amputation of the hand through the distal carpal row. The severity of the injury was such that it had avulsed the soft tissues from the forearm and the skin from the level of the arm as though a full sleeve of a shirt was being ripped off. Due to the extensive damage in multiple planes, the amputated part could not be saved. The below-elbow amputation stump though was covered with a new local flap based on the interosseous membrane and the periosteal flaps from the radius and ulna. The stump healed well and the patient recovered the full range of elbow movements.

Keywords: Degloving injuriy, periosteal flaps, avulsion amputation


How to cite this article:
Patil RK, Malhotra G, Venugopal S, Cherian M, Al Harthy A. A rare case: Avulsion amputation of the hand with degloving of the soft tissues from the level of the arm. Nigerian J Plast Surg 2015;11:63-7

How to cite this URL:
Patil RK, Malhotra G, Venugopal S, Cherian M, Al Harthy A. A rare case: Avulsion amputation of the hand with degloving of the soft tissues from the level of the arm. Nigerian J Plast Surg [serial online] 2015 [cited 2019 Dec 8];11:63-7. Available from: http://www.njps.org/text.asp?2015/11/2/63/178451


  Introduction Top


In degloving injuries, the skin is peeled off the underlying soft tissues. Though it can involve any part of the body, extremities are the most commonly involved sites.[1],[2] The anatomical arrangement in the extremities is such that the skin receives its circulation via direct, fasciocutaneous, and musculocutaneous perforators from the underlying source vessels.[3],[4] Avulsion injury destroys these flimsy attachments and the circulation in the avulsed skin flap is usually compromised and is difficult to restore.[5]

Avulsion injuries have been initially classified by Hidalgo into three groups.[6] Type1 injuries are common injuries with lacerations and visible avulsed flap, type2 injuries are atypical injuries where degloving is not obvious, and type3 injuries are limited to specific areas. Depending on the severity, these lesions can be classified into one of the four types (limited areas of abrasion/avulsion, noncircumferential degloving, circumferential degloving in a single plane, and circumferential multiplane degloving).[7] Morel Lavallée lesion (MLL) is another important type of closed degloving associated with pelvic and thigh injuries.[8]

Degloving injuries of the extremities pose multiple difficult challenges for a reconstructive surgeon such as assessing the viability of the avulsed skin, debridement of the devitalized tissues in the bed, attempt to save the viable part of the avulsed tissue, further coverage of the exposed vital structures, and finally achieving sound wound closure.[9],[10],[11] These attempts are often complicated by the extent of contamination and infection that set in quickly in case of extensive injuries.[9]

We present a case of avulsion amputation of the hand through the wrist, with circumferential degloving of the skin from the upper arm. The avulsed tissue could not be salvaged; though the below elbow amputation stump could be covered with an innovative use of local tissues. Our literature search did not reveal any reported case of such extensive avulsion of the skin with amputation of the hand.


  Case Report Top


A 23-year-old male presented to us with avulsion amputation of his left hand through the wrist with circumferential degloving of the skin through the upper arm. Part of the upper arm skin sustained closed degloving and a small part of the mid-arm skin, though degloved, was retained by a small posterior attachment. It was a worksite injury in which the patient's wrist got trapped under the conveyer belt of a machine. Forward pull by the machine and the patient trying to pull his hand out resulted in amputation of the hand and avulsion of the soft tissue and skin.

The patient presented to us around 4.5h after the injury. At the time of presentation, his vitals were stable, there was no ongoing blood loss, and he did not have associated injuries. After a brief history, radiographs were obtained of the upper limb and relatively well-preserved amputated part. The radiographs revealed amputation of the hand through the intercarpal level [Figure 1]. The amputated part was examined and was found to contain most of the flexor tendons avulsed from musculotendinous junctions, along with the nerves and vessels [Figure 2]. The patient was rushed to the emergency operation theater.
Figure 1: Avulsion amputation of the left hand with degloving of the skin from the arm in a young male. X-ray images showing the amputation though the mid-carpal level and the soft tissue shadow of the avulsed tissues from the mid forearm and distal forearm. The amputated part from the dorsal and volar aspects is seen with obvious entrapment at the level of the wrist (probably leading to avulsion of the soft-tissue envelope)

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Figure 2: From the dorsal and volar aspect of the proximal stump. (a) From the volar side, the damage to the muscles including the pronator qudratus and avulsion of all the tendons, neurovascular structures, and soft tissue can be appreciated. (b) the dorsal wound showing a similar avulsion injury with few preserved musculotendinous units [inserting above the wrist (brachioradialis)] can be seen. Contamination can be appreciated

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Under anesthesia and high arm tourniquet control, the limb was prepared. Examination revealed that the limb had sustained extensive crush injury in multiple planes; there was severe contamination and the vessels and nerves avulsed from the area just distalto the bifurcation of the brachial artery. The muscles were partly damaged due to the avulsion injury [Figure 2]a. The anterior interosseous vessels were preserved up to the mid-forearm. On the extensor aspect, the muscles and tendons were exposed, and the long extensors to the fingers were also avulsed as on the flexor side [Figure 2]b. Severe avulsion of tissues in different planes with crushing and contamination of the underlying tissues precluded the possibility of replantation.

All the contaminated devitalized muscles and exposed tendons were sharply debrided. The skin over the upper arm, though degloved, showed satisfactory circulation [Figure 3]a. The skin over the middle third had some posterior attachment and was retained after debriding the underlying contaminated fascia [Figure 3]a. Split-thickness skin graft was harvested from the avulsed part for possible further use to cover the stump. The postoperative period was uneventful. The patient was taken up for a relook debridement after 48 h. The retained muscles appeared viable except for part of the mid-arm skin [Figure 3]b and the harvested skin graft was applied over the lower arm and around the elbow [Figure 3]c and [Figure 3]d.
Figure 3: The amputated part was prepared and the skin graft was harvested from the same (a). The stump after debridement and a couple of dressings and the harvested skin graft from the avulsed tissue (b). The volar and dorsal aspects of the forearm after application of the skin graft (c and d)

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The patient was managed with regular dressings and after adequate counseling regarding the need of shortening of the extremity for fixation of appropriate prosthesis. he was taken up for revision amputation and coverage of the stump with a pedicle or a free flap. On exploration, the vessels in the area appeared inflamed and the possibility of the anastomosis being within the zone of injury, precluded the option of free flap.

While looking for possible options for reconstruction, the available local tissue appeared to be promising. The periosteum was viable and was bleeding till the end of the stump. With lateral incisions over the periosteum of the radius and the ulna, periosteal flaps were raised circumferentially distal to the intended level of revision of the stump [Figure 4]a. Attachment of these flaps with the interosseous membrane was left intact [Figure 4]b. The proximal parts of this flap had some viable muscle on the extensor aspect. After raising the flaps adequately, the ostectomies of the radius and ulna were performed [Figure 4]c. The flap thus obtained was substantial and had dimensions of 14×6 × 1.5 cm [Figure 4]d. The flap was used to cover the amputation stump all around [Figure 5]. In the proximal forearm and around the elbow, sufficient muscle bulk was present to support the skin graft. The raw areas were dressed and further managed with regular dressings. The initial graft take (of the graft harvested from avulsed skin) was around 50–60%. The residual raw areas and the flap were subsequently covered with skin graft from the thigh.
Figure 4: A flap based on the soft tissue and periosteum of both the radius and ulna and the interosseous membrane was being dissected. The periosteum was raised with two lateral incisions over the radius and ulna. The attachment with the interosseous membrane was preserved (a and b). The flap was quite substantial and was exactly available where it was most needed (c and d)

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Figure 5: The completely inset flap covering the stump from the volar (a) and the dorsal (b) aspects

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The patient was in the hospital as an inpatient for 18 days and was subsequently followed up in the clinic. Complete wound healing was achieved in 30 days from the date of injury. Athermoplastic splint was applied subsequently for positioning the elbow in 90° flexion and the patient was advised to remove the splint and do a range of motion exercises [Figure 6]a. The patient has completed 6 months of follow-up and has recovered the full range of elbow movements [Figure 6]b,[Figure 6]c,[Figure 6]d. The stump is well-covered with soft tissues and the patient is due to get prosthesis fashioned and applied. He has been re-employed in the same company with a change in his job profile.
Figure 6: Well-settled amputation without any edema and contractures at 6 months after injury can be appreciated (a) and the temporary splint the patient was using in the early postoperative period (b). The stump and range of movements at the elbow were normal (c and d)

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  Discussion Top


Extremity degloving injuries are usually an end result of run-over injuries or industrial accidents. The skin is avulsed from the deeper tissues due to the shearing force exerted over the skin following entrapment of body parts in roller machines and conveyer belts in case of industrial accidents. Similar injury results following crushing of the limb between the moving wheel and the road in case of run-over injuries.[2],[10],[12] Though such injuries can occur in any part of the body, extremities are more commonly involved.[13] Avulsion amputations are a severe form of these injuries where usually the projecting body parts get accidently trapped in rotating machine shafts and the tissues, in turn, are avulsed and detached to a variable extent. Avulsion amputation of the scalp,[14],[15] penis,[16] part of the face,[17] and even bilateral upper extremity has been described.[18]

Although reattachment of the avulsed tissue back in place is more desirable and can have functionally and aesthetically better outcomes, it is not always possible. The mechanism of injury, composition of the avulsed tissue, the extent of damage to the underlying tissues, and dimensions of the avulsed tissue need careful assessment. When the tissues are supplied by the defined vessels and the plane of avulsion is such that it does retain sufficient connection of these vessels to the overlying skin, replantation can be attempted. Successful replantation of the avulsed digits, scalp, penile skin, and even composite facial tissues has been reported.[14], 15, [17],[18],[19],[20] In the extremities, the skin is supplied by multiple fasciocutaneous and musculocutaneous perforators at different levels.[3],[4],[12] This makes reattaching the tissue back in place difficult. The skin is also directly traumatized most of the times in these injuries. In the given case, the injury was much more extensive and involved multiple planes; hence, replantation was not possible.

The proximal stumps/wounds in most of these cases are contaminated and need serial debridements and dressings before they are ready for reconstructive procedures.[9],[10] The distal/avulsed tissue can be used as a spare tissue and part of the tissue can be available for autologous transplantation.[21] Skin graft harvesting from the avulsed flap has been described and will help in reducing future donor site morbidity.[22] Even composite flaps can be harvested from avulsed and amputated tissues that are not suitable for replantation but will need microsurgical transfer for their reattachment.[23] Skin graft was harvested from the amputated skin in our case while due to the nature of the injury, a composite flap was not possible.

Ideally, below-elbow amputation stump should have a length of 15–18 cm from the elbow joint line and should be covered with healthy tissue.[24],[25] Free tissue transfer has been described to salvage amputation stumps following below-elbow amputation and below-knee amputation.[25],[26] After wound preparation, the patient was taken up for definitive closure. It was 7 days since the injury when a flap was planned. The vessels and the area appeared inflamed and well within the zone of trauma. The failure rate of free flap between the 5th day to the 3rd week has been reported to be higher.[27],[28]

The available local pedicle flaps were groin flap, abdominal flap,[29] and extended rectus abdominis myocutaneous perforator-based flap. The reach and positioning of the flaps and the postoperative care would have been difficult with the extent of the raw areas. A random abdominal flap or rectus abdominis myocutaneous flap was a possible option but had multiple disadvantages such as: (1) It would have been bulky and would have covered only the distal part of the stump.(2) As the raw area was extending to the upper third of the arm, with doubtful skin in the middle third, skin-to-skin attachment would not have been possible. (3) With no skin-to-skin attachment, it would have needed an extended period of attachment with the recipient site, before the flap division. (4) With multiple raw areas, wound management would have been difficult. (5) With no skin continuity, the flap would have had problems with lymphatic drainage, persistent edema, and recurrent infections.

The flap that has been used is a local flap, available in the vicinity, robust in blood supply and generous in size. It is composed of the periosteum and the interosseous membrane well vascularized by the overlying muscles and the anterior interosseous artery. The flap held the bones together and sealed the medullary cavities with periosteum.[30] With the extent of injury, even a large free flap like latissimus dorsi with anastomosis in the arm; may have reached the defect only with difficulty and with doubtful part of the flap lying over the critical part of the defect.[31]

The flap settled and granulated well within a week and the wound could be grafted. The swelling settled and with decreasing tissue edema, the patient rapidly regained the range of elbow movements. This flap is expected to be durable and is unlikely to have breakdown. As the other potential donor sites have not been touched, they are readily available in case of any unforeseen complication.


  Conclusion Top


Circumferential avulsion injury of the whole arm skin with amputation of the hand is rare. The tissue that is avulsed and amputated should be saved as much as possible, if possible by replantation and otherwise by using maximum tissues from the injured part that is to be discarded. In the presented case, the periosteal flap used for covering the amputation stump, along with skin graft, helped us in reducing the patient's morbidity.

No help has been received from any commercial organization for this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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