Degloving Injury Management

Algorithm Steps

1. ▶

   Start

   Degloving Injury

   Traumatic separation of skin from fascia

   1. ●

      Action

      Types of Degloving

      Open vs Closed

      • OPEN DEGLOVING:
      • - Visible skin separation
      • - Skin may be attached or avulsed
      • - Common: Extremities, fingers
      • CLOSED DEGLOVING (Morel-Lavallée):
      • - Skin intact externally
      • - Internal shearing of fascia
      • - Collection of blood/lymph
      • - Often missed on initial exam
      • - Common: Thigh, pelvis, trunk
      1. ●

         Action

         Arnez Classification

         Open degloving severity

         • PATTERN 1: Abrasion/Limited degloving
         • - Skin loss <100 cm²
         • - Usually heal with conservative care
         • PATTERN 2: Non-circumferential degloving
         • - Larger area, one plane preserved
         • - May reattach or graft
         • PATTERN 3: Circumferential single-plane
         • - Complete circumferential injury
         • - Significant vascular compromise
         • PATTERN 4: Circumferential multi-plane
         • - Muscle, nerve, vessel exposure
         • - Worst prognosis
         1. ●

            Action

            Viability Assessment

            Determine what can be saved

            • CLINICAL SIGNS:
            • - Color (pink vs pale vs dusky)
            • - Capillary refill
            • - Dermal bleeding on incision
            • - Turgor
            • ADJUNCTS:
            • - Fluorescein test (1g IV, Wood's lamp)
            • - Laser Doppler
            • - ICG angiography
            • TIMING:
            • - Assess at 24-48h (more accurate)
            • - Serial reassessment
            1. ⚠

               Warning

               Initial Management

               Emergency care

               • RESUSCITATION:
               • - Large blood loss common
               • - Associated injuries (fractures)
               • WOUND CARE:
               • - Copious irrigation
               • - Debride necrotic tissue
               • - Preserve questionable tissue initially
               • - Tetanus, antibiotics
               • TEMPORIZING:
               • - Moist dressings
               • - VAC therapy
               • - Keep degloved skin (may use as graft)
               1. ◆

                  Decision

                  Treatment Based on Viability

                  Viable vs Non-viable skin

                  1. ●

                     Action

                     Viable Degloved Skin

                     Attempt to save

                     • REPLANTATION OPTIONS:
                     • - Primary reattachment if circulation OK
                     • - Quilting sutures to prevent seroma
                     • - Drain placement
                     • - VAC over flap
                     • MONITORING:
                     • - Serial exam for viability
                     • - Be prepared for failure
                     1. ●

                        Action

                        Definitive Reconstruction

                        Coverage options

                        • GRAFTS:
                        • - FTSG from degloved skin (ideal)
                        • - STSG from donor site
                        • FLAPS (if needed):
                        • - Local flaps
                        • - Regional pedicled flaps
                        • - Free flaps for large defects
                        • TIMING:
                        • - Early closure reduces infection
                        • - Wait for clean granulating bed
                        1. ✓

                           Outcome

                           Outcomes

                           Expected results

                           • Functional recovery variable
                           • Sensation usually impaired
                           • Cosmesis often suboptimal
                           • Multiple revision surgeries common
                           • Ring degloving: High amputation rate
                           • Long-term PT/OT needed
                  2. ●

                     Action

                     Non-Viable Degloved Skin

                     Salvage skin for grafting

                     • FULL-THICKNESS GRAFT HARVEST:
                     • - Harvest FTSG from avulsed skin
                     • - Defat carefully
                     • - Store in saline (refrigerate)
                     • - Bank for delayed grafting
                     • WOUND BED PREPARATION:
                     • - Serial debridement
                     • - VAC therapy for granulation
                     • - Usually 7-14 days before grafting
      2. ●

         Action

         Morel-Lavallée Lesion

         Closed degloving management

         • DIAGNOSIS:
         • - Fluctuant swelling
         • - MRI confirms collection
         • - May present days later
         • TREATMENT OPTIONS:
         • - Aspiration + compression (small)
         • - Percutaneous drainage (larger)
         • - Open debridement (organized)
         • - Sclerosing agents (talc, doxycycline)
         • HIGH RECURRENCE RATE