How do you classify and manage a degloving injury where the thin skin is pulled back?

Management of Degloving Injuries

Degloving injuries should be managed with immediate wound cleansing, careful preservation of viable tissue, and appropriate surgical intervention including excision, defatting, and reapplication of the degloved skin as a full-thickness skin graft to reduce morbidity and mortality. 1, 2, 3

Classification of Degloving Injuries

Degloving injuries can be classified into three patterns:

1. Pure degloving injury: Only skin and subcutaneous tissue are avulsed
2. Degloving with deep soft tissue involvement: Skin avulsion with damage to underlying muscles/tendons
3. Degloving with bone fractures: Skin avulsion with associated fractures 4

Degloving injuries are also considered a specific feature of severity in trauma patients according to the Vittel criteria, which may prompt admission to a specialized trauma center 1.

Initial Management

Assessment and Stabilization

• Evaluate for signs of active hemorrhage and control bleeding immediately
• If direct compression is ineffective or there are multiple injuries requiring simultaneous management, application of a tourniquet may be necessary 1
• Assess for associated injuries, particularly fractures or vascular compromise
• If an injured extremity appears blue or extremely pale, activate emergency medical services immediately 1

Wound Care

1. Cleansing:

   • Gently cleanse the wound with sterile normal saline or clean water 2
   • Remove visible debris without applying excessive pressure 2
   • Avoid iodine or antibiotic solutions for routine cleansing 2

2. Tissue Management:

   • Handle the skin carefully to minimize further epidermal detachment 1
   • For fresh tears (less than 8 hours old), consider approximating wound margins with Steri-Strips 2
   • Decompress blisters by piercing and expressing or aspirating fluid 1, 2
   • The detached, lesional epidermis may be left in situ to act as a biological dressing 1

Definitive Management

Surgical Approach

The evidence strongly supports that degloved skin should be excised, defatted, fenestrated, and reapplied as a full-thickness skin graft 5, 3, 4. This approach has shown the most satisfactory coverage of denuded areas compared to attempting to salvage the entire flap with its subcutaneous tissue 3.

Key surgical steps include:

1. Radical debridement of non-viable tissue 4
2. Processing the degloved skin with sharp scalpels to create full-thickness skin grafts 4
3. Repositioning and securing the grafts with multiple sutures 4

Dressing Options

1. Primary dressing:

   • Apply a non-adherent dressing directly to the wound (e.g., Mepitel or Telfa) 1, 2
   • Apply a greasy emollient (50% white soft paraffin with 50% liquid paraffin) over denuded areas 1, 2

2. Secondary dressing:

   • Apply a secondary foam dressing to collect exudate (e.g., Exu-Dry) 1
   • Consider Vacuum-Assisted Closure (VAC) therapy as an effective alternative to traditional dressings 5, 6
   • For complex wound geometries, gauze-based wound fillers can be easily applied for skin graft immobilization 6

Monitoring and Follow-up

• Daily observation until the flap becomes fixed is mandatory 3
• Monitor for signs of infection: increasing pain, erythema extending >5cm beyond wound margins, temperature >38.5°C, or heart rate >110 beats/minute 2
• Apply topical antimicrobials only to sloughy areas, not to clean wounds 2
• Consider systemic antibiotics only if there are signs of spreading infection or systemic symptoms 2

Special Considerations

• Extensive injuries: Consider transfer to a specialized center for degloving injuries with significant epidermal loss or signs of clinical deterioration 1
• Age factor: Younger patients with severe degloving injuries (Pattern 3) achieve higher primary healing rates than older patients 4
• Facial degloving: Extremely rare and requires specialized management with focus on preventing necrosis and infection through surgical debridement and timely repair of vital soft tissue structures 7

Pitfalls to Avoid

1. Primary reattachment without grafting: Suturing the degloved skin back or using compression dressings without proper grafting is unsuccessful and should be avoided 3
2. Delayed debridement: Failure to promptly remove non-viable tissue increases risk of infection and poor outcomes
3. Inadequate monitoring: Daily observation is essential to detect early signs of complications
4. Overaggressive fluid resuscitation: Can lead to pulmonary, cutaneous, and intestinal edema in extensive cases 1

By following this structured approach to degloving injuries, clinicians can optimize outcomes and reduce the significant morbidity associated with these severe traumatic injuries.