What is the initial management for a degloving injury?

Initial Management of Degloving Injury

Degloving injuries require immediate recognition as severe trauma with transport to a specialized Trauma Centre, control of active hemorrhage with tourniquet if direct compression fails, and urgent surgical debridement with full-thickness skin grafting as the definitive treatment approach. 1

Immediate Recognition and Triage

• Degloving injuries are specific features of severity that trigger immediate transport to a specialized Trauma Centre based on Vittel criteria, regardless of other physiologic parameters 1
• These injuries fall under the anatomic criteria requiring the highest level of trauma care, specifically listed as "crushed, degloved, mangled, or pulseless extremity" 1
• Degloving injuries are frequently underestimated and may be missed at initial assessment in up to one-third of patients, making systematic evaluation critical 2, 3
• The diagnosis can be overlooked in multiply injured patients, requiring high clinical suspicion 3

Hemorrhage Control

For active limb hemorrhage that fails direct compression, immediate tourniquet application is recommended 1

• Direct manual compression with pressure dressing should be attempted first for accessible bleeding 1
• Tourniquet indications in degloving injuries include: inefficiency of direct compression, presence of foreign body within the hemorrhagic wound, lack of radial pulse (hemodynamic instability), or need for multiple simultaneous actions 1
• The tourniquet must be re-evaluated as soon as possible to minimize ischemic time and limit morbidity 1
• Avoid iterative tourniquet releases, as this aggravates both local muscle injury and systemic rhabdomyolysis 1

Initial Wound Management

• Cover the degloving injury immediately with cling film or nonadherent dressing to prevent further trauma, reduce pain, and minimize infection exposure 1
• Apply emollient or barrier cream to any areas requiring manipulation to reduce friction damage 1
• Immobilize the affected extremity to prevent further tissue damage 4
• Avoid applying any adhesive materials directly to injured skin 1

Assessment for Associated Injuries

Degloving injuries commonly occur with high-energy trauma and require systematic evaluation for:

• Vascular compromise: assess for absent or diminished pulses, active hemorrhage, and signs of ischemia (pallor, coolness, diminished sensation) 5
• Compartment syndrome: evaluate for pain disproportionate to injury, pain on passive muscle stretching, paresthesia, and late findings of pallor and diminished pulses 5
• Deep soft tissue involvement and long-bone fractures, which significantly impact prognosis 2
• Associated injuries occur in 51-79% of cases with vascular involvement 1

Definitive Surgical Management

Immediate radical debridement followed by full-thickness skin grafting using the degloved skin provides the most satisfactory outcomes 4, 2

• The degloved skin should be processed as full-thickness or split-thickness graft using sharp scalpels in situ 2
• Primary reattachment of the flap by suture or compression dressings without grafting is unsuccessful and should be abandoned 4
• Mesh grafts should be used when necessary to cover large areas 4
• Multiple sutures after graft repositioning improve skin graft take 2

Critical Pitfalls to Avoid

• Do not attempt primary reattachment of the degloved tissue without converting it to a graft - this approach has poor outcomes and high failure rates 4
• Do not delay surgical intervention, as degloving injuries are associated with high morbidity and mortality if mismanaged 2
• Do not underestimate the extent of injury - these lesions are frequently more severe than initial appearance suggests 2
• Avoid missing the diagnosis in multiply injured patients by maintaining systematic evaluation protocols 3

Post-Procedure Monitoring

• Daily observation until the graft becomes fixed is mandatory to detect early complications 4
• Frequent observation and continued immobilization of the extremity postoperatively are essential 4
• Monitor for signs of infection, necrosis, and graft failure requiring secondary intervention 4, 2
• Delayed necrosis can occur when effective compression cannot be applied to extensive degloving areas 3