practice
Degloving injuries of the abdominal wall l Objective: To stress the local, regional and global impact of degloving injuries of abdominal wall based on which the surgeon can design the management protocol. l Method: A retrospective series of seven cases who met with high velocity run-over accidents between the year 2002 to 2007. All patients were clinically examined and the findings confirmed radiologically, which guided the management. l Results: Out of the seven patients treated, six survived. All patients had open degloving injury of abdominal wall and in different areas of the lower limbs, while three had an additional closed degloving in the back, thighs and gluteal regions. All of them had pelvic fractures of various types.Three patients had peritoneal injury, of whom one had additional diaphragmatic injury. None of them had hollow viscus perforation or injury to solid viscera despite the varied severity of injuries to the abdominal wall, pelvic bone and diaphragm. l Conclusion: Degloving injuries of the abdominal wall are rarely encountered in our practice. The associated morbidity and mortality are very high. However, the prognosis can be improved by successful revival and rehabilitation of these patients, which is possible by early resuscitation, recognition of all bony and soft tissue injuries, early debridement and coverage. l Declaration of interest: There were no external sources of funding for this study. The authors have no conflicts of interest to declare with regard to the manuscript or its content.
degloving injuries; abdominal aponeurosis; abdominal viscera; hollow viscus; shearing force
562
on the basis of which the surgeon can design the management protocol. The extent of degloving, friction injuries, skin loss, different types of associated pelvic fractures and other injuries are emphasised. The concerns, current approaches and their limitations in our patients are also highlighted.
Method All patients in our series presented to the accident and emergency department (A&E) of our hospital, a tertiary centre, during 2002–2007 with degloving injuries of the abdominal wall following high-velocity road traffic accidents. All patients were clinically assessed on arrival to the hospital. Bony injuries were confirmed by radiological examination. Computed tomography (CT) scans were performed only in patients who had peritoneal injury seen through the open abdominal wound, in order to assess the intra-abdominal organs. Pre-operative urethrogram was performed in patients with pelvic fracture and suspected urethral injury.
Management Patients were assessed by a multidisciplinary team of intensivists, orthopaedic surgeons, general surgeons, plastic surgeons and urologists at the A&E. They were initially resuscitated and then clinically examined to assess the nature and extent of injuries. Clinical findings were confirmed by radiological investigations. CT scans of the abdomen was done
ltd
D
egloving injuries of the anterior abdominal wall are quite rare compared with those of extremities or scalp, as the mechanism and forces acting are different. In the extremities, bone provides a solid counteractive force, whereas in the abdominal wall, degloving occurs against the musculo-aponeurotic layer, which is a tough structure comparable to bone.1 The severity of degloving is proportional to magnitude of external force. These injuries are generally described as: l Open or anatomical degloving injury When a tangential external force of sufficient magnitude is applied to the body surface, a sudden shearing tears the skin and subcutaneous tissues away from the underlying solid skeletal structures. The separation of tissue planes injures blood vessels, resulting in compromised circulation to the overlying tissues.2 l Closed or physiological degloving This is also known as a Morel-Lavallée lesion, which is the result of traumatic shearing of skin and subcutaneous tissues from deep fascia, without any open wound.3 This may present as abnormally loose skin, as it lacks normal connections to underlying tissues. The overlying skin may sometimes also be bruised. It leaves a large dead space with haematoma.4 Here, we present a series of patients with degloving injuries of the abdominal wall. The aim of this paper is to stress the local, regional and global impact of degloving injuries of the abdominal wall,
© 2013 MA Healthcare
Veena P.W. , MCh R. Babu,1 MCh, FRCS; M.S.Venkatesh,1 MCh Udayashankar,1 FRCS (Edin), FRCS (Glas); K.L. Deepak,1 MCh; 1 Department of Plastic Surgery, M.S. Ramaiah Hospitals, Bangalore, Karnataka, India. Email: veenaprabhakar2003@ yahoo.com 1
j o u r n a l o f wo u n d c a r e v o l 2 2 , n o 1 0 , O c to b e r 2 0 1 3
ournal of Wound Care. Downloaded from magonlinelibrary.com by 129.100.058.076 on December 11, 2015. For personal use only. No other uses without permission. . All rights reserved
practice in patients with clinically obvious peritoneal tear and suspicion of diaphragmatic injury, when gurgling sounds were heard on auscultation of chest. Pneumothorax and haemothorax were assessed by chest X-ray, CT and ultrasound scans. Patients received tetanus prophylaxis and antibiotics were administered according to hospital antibiotic policy: 12-hourly intravenous (IV) ceftriaxone 1g and 8-hourly metronidazole in A&E, and 12-hourly amikacin 500mg after the creatinine reports were available. Antibiotics were changed later, according to culture and sensitivity reports correlated with clinical response. Morphine 0.1mg/kg body weight was administered for pain relief, after preliminary examination. Global haemodynamics were assessed by hourly urine output, heart rate, blood pressure, central venous pressure monitoring, haemoglobin and packed-cell volume. Blood components and IV fluids were administered accordingly. Electrolyte losses were assessed by serial laboratory estimations of serum sodium, potassium, chloride, calcium, arterial blood gases and necessary corrections made. Sepsis was assessed by monitoring temperature, respiratory rate, heart rate, blood pressure, central venous pressure, reduced bowel sounds and urine output. Laboratory parameters, such as total leukocyte count, platelet count, serum electrolytes, arterial blood gases, liver function test and chest X-ray were serially conducted as per intensive care unit (ICU) protocol. Serial wound, blood and urine cultures were done to guide antibiotic therapy.
Primary surgical procedures in the form of stabilisation of pelvic and long bone fractures, and wound debridement were carried out. Exploratory laparotomy was performed in patients with peritoneal tear. The adequacy of debridement and tissue viability was assessed based on the colour of tissues and bleeding from incised edges of dermis, as it is the key to flap survival. Closed degloving injuries were managed by evacuation of haematoma, by making incision in the degloved part, lavage and placement of suction drains. The site of incision for draining the haematoma was chosen carefully by avoiding the possible future flap territories. Peritoneal and muscle defects were repaired directly, whereas larger abdominal muscle defects were reconstructed with flaps. Abdominal wound resurfacing was done with split-thickness skin grafts (STSGs). Following surgery, pain was assessed by a visual analog scale (VAS) and managed as per the following protocol: l 6-hourly morphine 4mg injection in adults (0.05mg/kg in children) during the postoperative period following repeated surgeries, and on request if VAS > 6 while in the ICU j o u r n a l o f wo u n d c a r e v o l 2 2 , n o 1 0 , O c to b e r 2 0 1 3
No. Age Gender Defect site/extent Outcome 1 22 Male 16×40cm abdominal wall defect, with exposed fascia and aponeurosis
Wound infection, 50% graft take Wound healed after 30 days
2 32 Female 14×26cm abodominal wall defect; Necrosis distal Muscle defect 7×6cm in the area margin of of abdominal wall rupture, with herniation degloved flap of the small bowel Wound healed by day 42 3 28 Male
10×22cm defect exposing aponeurosis, muscle and anterior superior iliac spine
4 20 Male
8×15cm defect exposing aponeurosis and Graft take 100% iliac crest by day 5
5 5 Female 6×15cm abdominal wall defect with exposed injured peritoneum and muscle
Graft take 100% by day 7
Marginal necrosis of degloved flap; Well settled flap and graft by day 6
6 22 Female
15×40cm defect with exposed abdominal Graft well settled muscle, fascia and iliac crest by day 6
7 24 Female
Defect of the anterior abdominal wall, from lower thoracic spine to gluteal crease on the back and circumferential degloving of buttocks and thighs
Death
8-hourly slow IV/intramuscular (IM) tramadol 50mg injection in adults if VAS score 4–6 while in ICU l 6-hourly diclofenac 75mg IM injection in adults (1mg/kg in children) or 500mg acetaminophen tablet in adults (15mg/kg in children) in wards, if VAS
Degloving injuries of the abdominal wall l Objective: To stress the local, regional and global impact of degloving injuries of abdominal wall based on which the surgeon can design the management protocol. l Method: A retrospective series of seven cases who met with high velocity run-over accidents between the year 2002 to 2007. All patients were clinically examined and the findings confirmed radiologically, which guided the management. l Results: Out of the seven patients treated, six survived. All patients had open degloving injury of abdominal wall and in different areas of the lower limbs, while three had an additional closed degloving in the back, thighs and gluteal regions. All of them had pelvic fractures of various types.Three patients had peritoneal injury, of whom one had additional diaphragmatic injury. None of them had hollow viscus perforation or injury to solid viscera despite the varied severity of injuries to the abdominal wall, pelvic bone and diaphragm. l Conclusion: Degloving injuries of the abdominal wall are rarely encountered in our practice. The associated morbidity and mortality are very high. However, the prognosis can be improved by successful revival and rehabilitation of these patients, which is possible by early resuscitation, recognition of all bony and soft tissue injuries, early debridement and coverage. l Declaration of interest: There were no external sources of funding for this study. The authors have no conflicts of interest to declare with regard to the manuscript or its content.
degloving injuries; abdominal aponeurosis; abdominal viscera; hollow viscus; shearing force
562
on the basis of which the surgeon can design the management protocol. The extent of degloving, friction injuries, skin loss, different types of associated pelvic fractures and other injuries are emphasised. The concerns, current approaches and their limitations in our patients are also highlighted.
Method All patients in our series presented to the accident and emergency department (A&E) of our hospital, a tertiary centre, during 2002–2007 with degloving injuries of the abdominal wall following high-velocity road traffic accidents. All patients were clinically assessed on arrival to the hospital. Bony injuries were confirmed by radiological examination. Computed tomography (CT) scans were performed only in patients who had peritoneal injury seen through the open abdominal wound, in order to assess the intra-abdominal organs. Pre-operative urethrogram was performed in patients with pelvic fracture and suspected urethral injury.
Management Patients were assessed by a multidisciplinary team of intensivists, orthopaedic surgeons, general surgeons, plastic surgeons and urologists at the A&E. They were initially resuscitated and then clinically examined to assess the nature and extent of injuries. Clinical findings were confirmed by radiological investigations. CT scans of the abdomen was done
ltd
D
egloving injuries of the anterior abdominal wall are quite rare compared with those of extremities or scalp, as the mechanism and forces acting are different. In the extremities, bone provides a solid counteractive force, whereas in the abdominal wall, degloving occurs against the musculo-aponeurotic layer, which is a tough structure comparable to bone.1 The severity of degloving is proportional to magnitude of external force. These injuries are generally described as: l Open or anatomical degloving injury When a tangential external force of sufficient magnitude is applied to the body surface, a sudden shearing tears the skin and subcutaneous tissues away from the underlying solid skeletal structures. The separation of tissue planes injures blood vessels, resulting in compromised circulation to the overlying tissues.2 l Closed or physiological degloving This is also known as a Morel-Lavallée lesion, which is the result of traumatic shearing of skin and subcutaneous tissues from deep fascia, without any open wound.3 This may present as abnormally loose skin, as it lacks normal connections to underlying tissues. The overlying skin may sometimes also be bruised. It leaves a large dead space with haematoma.4 Here, we present a series of patients with degloving injuries of the abdominal wall. The aim of this paper is to stress the local, regional and global impact of degloving injuries of the abdominal wall,
© 2013 MA Healthcare
Veena P.W. , MCh R. Babu,1 MCh, FRCS; M.S.Venkatesh,1 MCh Udayashankar,1 FRCS (Edin), FRCS (Glas); K.L. Deepak,1 MCh; 1 Department of Plastic Surgery, M.S. Ramaiah Hospitals, Bangalore, Karnataka, India. Email: veenaprabhakar2003@ yahoo.com 1
j o u r n a l o f wo u n d c a r e v o l 2 2 , n o 1 0 , O c to b e r 2 0 1 3
ournal of Wound Care. Downloaded from magonlinelibrary.com by 129.100.058.076 on December 11, 2015. For personal use only. No other uses without permission. . All rights reserved
practice in patients with clinically obvious peritoneal tear and suspicion of diaphragmatic injury, when gurgling sounds were heard on auscultation of chest. Pneumothorax and haemothorax were assessed by chest X-ray, CT and ultrasound scans. Patients received tetanus prophylaxis and antibiotics were administered according to hospital antibiotic policy: 12-hourly intravenous (IV) ceftriaxone 1g and 8-hourly metronidazole in A&E, and 12-hourly amikacin 500mg after the creatinine reports were available. Antibiotics were changed later, according to culture and sensitivity reports correlated with clinical response. Morphine 0.1mg/kg body weight was administered for pain relief, after preliminary examination. Global haemodynamics were assessed by hourly urine output, heart rate, blood pressure, central venous pressure monitoring, haemoglobin and packed-cell volume. Blood components and IV fluids were administered accordingly. Electrolyte losses were assessed by serial laboratory estimations of serum sodium, potassium, chloride, calcium, arterial blood gases and necessary corrections made. Sepsis was assessed by monitoring temperature, respiratory rate, heart rate, blood pressure, central venous pressure, reduced bowel sounds and urine output. Laboratory parameters, such as total leukocyte count, platelet count, serum electrolytes, arterial blood gases, liver function test and chest X-ray were serially conducted as per intensive care unit (ICU) protocol. Serial wound, blood and urine cultures were done to guide antibiotic therapy.
Primary surgical procedures in the form of stabilisation of pelvic and long bone fractures, and wound debridement were carried out. Exploratory laparotomy was performed in patients with peritoneal tear. The adequacy of debridement and tissue viability was assessed based on the colour of tissues and bleeding from incised edges of dermis, as it is the key to flap survival. Closed degloving injuries were managed by evacuation of haematoma, by making incision in the degloved part, lavage and placement of suction drains. The site of incision for draining the haematoma was chosen carefully by avoiding the possible future flap territories. Peritoneal and muscle defects were repaired directly, whereas larger abdominal muscle defects were reconstructed with flaps. Abdominal wound resurfacing was done with split-thickness skin grafts (STSGs). Following surgery, pain was assessed by a visual analog scale (VAS) and managed as per the following protocol: l 6-hourly morphine 4mg injection in adults (0.05mg/kg in children) during the postoperative period following repeated surgeries, and on request if VAS > 6 while in the ICU j o u r n a l o f wo u n d c a r e v o l 2 2 , n o 1 0 , O c to b e r 2 0 1 3
No. Age Gender Defect site/extent Outcome 1 22 Male 16×40cm abdominal wall defect, with exposed fascia and aponeurosis
Wound infection, 50% graft take Wound healed after 30 days
2 32 Female 14×26cm abodominal wall defect; Necrosis distal Muscle defect 7×6cm in the area margin of of abdominal wall rupture, with herniation degloved flap of the small bowel Wound healed by day 42 3 28 Male
10×22cm defect exposing aponeurosis, muscle and anterior superior iliac spine
4 20 Male
8×15cm defect exposing aponeurosis and Graft take 100% iliac crest by day 5
5 5 Female 6×15cm abdominal wall defect with exposed injured peritoneum and muscle
Graft take 100% by day 7
Marginal necrosis of degloved flap; Well settled flap and graft by day 6
6 22 Female
15×40cm defect with exposed abdominal Graft well settled muscle, fascia and iliac crest by day 6
7 24 Female
Defect of the anterior abdominal wall, from lower thoracic spine to gluteal crease on the back and circumferential degloving of buttocks and thighs
Death
8-hourly slow IV/intramuscular (IM) tramadol 50mg injection in adults if VAS score 4–6 while in ICU l 6-hourly diclofenac 75mg IM injection in adults (1mg/kg in children) or 500mg acetaminophen tablet in adults (15mg/kg in children) in wards, if VAS
