Degloving injuries are some of the most difficult reconstructive problems faced by hand and microsurgeons. The high energy of the injury is distributed over a wide area, and the cleavage plane often leaves no anastomosable vessels in the amputated part. Partial or total part necrosis and secondary completion amputations are common, as are dense fibrosis, significant neural compromise, and unstable scar in even successful replantations. The authors report a case of a successful salvage of totally degloved soft tissues of the hand from the level of the distal radio-ulnar joint to the fingertips. The neurovascular structures in the part were found intact in the hand to the level of the DIP joints. Replacement of the avulsed skin and soft tissues was performed with arteriovenous anastomosis from the radial artery to the cephalic vein in the amputated part, using an interposition vein graft. Reflow was incomplete to the digits. Therefore, the hand was de-epithelialized and implanted in a subcutaneous abdominal pocket for three weeks. Viable digital length was stabilized at the level of the PIP joints. Functional results were achieved with 50 degrees wrist flexion, 40 degrees wrist extension, and 20 degrees thumb abduction. Finger MCP joint motion was from 60 degrees flexion to 80 degrees flexion, or 20 degrees total active motion. The patient regained some sensation, with 2-pt discrimination > 12mm. He was able to use the hand as an assistive hand
This case documents many important principles of replantation of degloving injuries to the hand. Careful assessment of available vascular structures in both parts must be performed to determine the feasibility of vascular reattachment. Arteriovenous anastomosis is liberally used to augment absent arterial recipient vessels in the degloved tissue. Non-viable tissue must be debrided, and partially viable tissue can be salvaged, as in this case, by the use of distant flaps, either free or pedicled. Thus, maximal length can be restored to preserve some useful function in an otherwise non-functioning part. This creative use of multiple reconstructive techniques maximizes the preservation of remaining parts and eventually the patient's hand function, as well.
Journal of Reconstructive Microsurgery 19: 217-220, 2003.