Degloving injury
Skin and fat sheared off the deep fascia. Open (skin torn) or closed (Morel-Lavallée, skin intact). Often part of high-energy trauma. Finger ring avulsion: use the digital replantation pathway.
All Pathways
Plastic SurgeryEmergency
Degloving Injury Management
Degloving Injury Management: Degloving injury → First: primary survey and resuscitation (ATLS) → Limb threat: check perfusion and compartments now → Ini...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Warning First: primary survey and resuscitation (ATLS)
Treat life threats before the wound. Blood loss can be large, also into a closed degloving cavity.
- Control bleeding (direct pressure, packing or tourniquet) and resuscitate per the major trauma protocol. Unstable with uncontrolled bleeding: resuscitation and surgery at the same time.
- Anticoagulant or antiplatelet drug: higher bleeding risk. Life-threatening bleeding: reverse the anticoagulant per the major trauma bleeding protocol.
- Look for associated injuries: fractures (especially pelvis and acetabulum), vessels, nerves, tendons.
03Warning Limb threat: check perfusion and compartments now
Degloving care must not delay revascularisation or fasciotomy. Crush, roller or wringer injury: check CK and renal function (see rhabdomyolysis pathway).
- Pulseless deformed limb: realign and splint, then recheck. Absent pulses or ischaemic limb: CT angiography with the trauma CT; vascular surgery to start revascularisation within 1 h of arrival.
- Crush or circumferential injury: assess for compartment syndrome; if present, urgent fasciotomy (see compartment syndrome pathway).
- Repeat and record vascular and nerve checks, also after splinting.
04Action Initial wound care and early referral
In ED: protect the wound. Formal washout and debridement are done in theatre.
- Remove gross contamination only. Photograph the wound before it is dressed.
- Cover with saline-soaked gauze and an occlusive film.
- Highly contaminated wound (farm, soil, water, sewage) or vascular compromise: to theatre immediately. Water or soil contamination needs extra antibiotic cover (see below).
- Keep any detached avulsed skin in saline-moist gauze for the surgeon (possible graft).
- Tetanus-prone wound: give tetanus prophylaxis per the Australian Immunisation Handbook.
- Antibiotics: open fracture: see open fracture pathway. Contaminated or crush soft-tissue wound: first-generation cephalosporin (cefazolin) for 24 h or less. Severe beta-lactam allergy: use the local alternative.
- Fresh or salt water contamination: add cover for Aeromonas, Vibrio and Pseudomonas (for example ciprofloxacin). Soil or farm contamination: add high-dose penicillin for Clostridium. Give 3 to 5 days. Agent and dose per Therapeutic Guidelines or ID advice.
- Refer early to plastic surgery. Early review means fewer operations and a shorter stay.
05Decision Is the skin broken (open degloving)?
Yes: open degloving. No: skin intact over a mobile, fluctuant area (closed degloving, Morel-Lavallée). Both present: manage each area by its own branch.
- If Yes
06Action Open degloving: classify the pattern (Arnez)
The pattern predicts whether degloved skin survives if sutured back.
- Pattern 1: abrasion or avulsion.
- Pattern 2: non-circumferential degloving.
- Pattern 3: circumferential degloving in one plane (skin and fat off the deep fascia).
- Pattern 4: circumferential degloving in many planes (between and within muscles, or muscle off bone).
- Record deep injury: tendon, paratenon, nerve, vessel, bone, periosteum, joint.
07Action Open degloving: assess skin viability in theatre
Clinical signs are unreliable alone. Degloved skin can look viable at first and then die over days.
- Check colour, capillary refill and dermal bleeding when the skin is cut.
- Indocyanine green (ICG) angiography can help where it is available.
- Evacuate haematoma under the degloved skin.
- Reassess at each second look.
08Decision Non-circumferential (pattern 2) and skin viable?
Suturing back degloved skin succeeded only in pattern 2. Circumferential degloving (patterns 3 and 4) goes to excision.
- If Yes
09Action Pattern 2, viable skin: suture back and monitor
Only for non-circumferential degloving with viable skin. Do not suture back circumferential (pattern 3 or 4) degloved skin.
- Excise non-viable edges first.
- Suture back without tension.
- Examine the skin at each dressing change or second look.
- Skin becomes non-viable: excise it and cover the defect (next step).
10Action Definitive cover of an open wound (plastic surgery)
For an open wound or a skin defect after debridement. Closed lesions that settle need no cover. Cover once the bed is clean. Early cover lowers infection risk.
- Skin graft: from the degloved skin or a donor site.
- Dermal substitute, then split-thickness graft, is an option in some wounds.
- Exposed bone without periosteum, tendon without paratenon, or joint: flap cover (local, pedicled or free).
11Outcome Rehabilitation and follow-up
Plan for more operations, therapy and scar care.
- Physiotherapy or hand therapy.
- Sensation is often reduced.
- Further operations are common.
12End End of pathway
Specialist follow-up continues.
If No13Action Non-viable or circumferential: excise and cover
Radical excision of devitalised tissue, then cover. Pattern 4: serial debridement before reconstruction.
- Excise all non-viable skin and fat.
- Use the avulsed skin as a graft: defat it to full thickness or take a split-thickness graft from it.
- Patterns 1 to 3 with a clean bed: excise and cover in one operation.
- Negative pressure wound therapy can prepare the bed. Not over exposed, unprotected vessels or organs, an undrained abscess or an acutely ischaemic wound. Watch for bleeding if on anticoagulants.
- Stored skin loses viability with time. Store only per the unit protocol.
- Path rejoins step 10Shared downstream outcome
If No14Warning Closed degloving with pelvic or acetabular fracture: infection risk
Tell the orthopaedic team before fracture surgery.
- Cavity fluid is often colonised (46% positive cultures in one series).
- Treat the lesion before or at the time of fracture fixation.
- Examine the overlying skin daily: pressure necrosis can develop over days.
15Action Closed degloving (Morel-Lavallée): diagnose and treat
Often missed. Can present days to months after injury. Can bleed enough to cause shock.
- Signs: soft fluctuant swelling, mobile skin; bruising can appear late.
- Imaging: ultrasound; CT in major trauma; MRI defines the lesion best.
- Small acute lesion: compression and observation.
- Larger lesion: aspiration or drain plus compression. More than 50 mL aspirated predicts recurrence: consider surgery.
- Recurrent or chronic (capsule): sclerodesis or open debridement by a specialist.
- Skin necrosis or infection: surgical debridement; send fluid for culture.
- Path rejoins step 10Shared downstream outcome
Guideline Source
BOA/BAPRAS Standards for the Management of Open Fractures (2020): Degloving Injuries chapter; Arnez classification (JPRAS 2010)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Closed degloving (Morel-Lavallée) is often missed and can present late
- No high-level guideline: based on BOA/BAPRAS standards, cohort studies and reviews
- Clinical viability assessment is unreliable; necrosis can appear over days
- Further operations are common
Contraindicated Populations
Finger ring avulsion (use the digital replantation pathway)Penile or scrotal skin degloving (urology)Scalp or face avulsion (specialist pathways)
Applicable Regions
AUUSEUGlobal
AU: Tetanus prophylaxis per the Australian Immunisation Handbook. Antibiotic choice per Therapeutic Guidelines and local policy. Major trauma: early transfer to a major trauma service through the state retrieval service.
UK: BOA/BAPRAS open fracture standards (2020) and BOASTs apply.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Degloving Injury Management?
The Degloving Injury Management is a emergency clinical algorithm for Plastic Surgery. It provides a structured decision tree to guide clinical decision-making, based on BOA/BAPRAS Standards for the Management of Open Fractures (2020): Degloving Injuries chapter; Arnez classification (JPRAS 2010).
What guideline is the Degloving Injury Management based on?
This algorithm is based on BOA/BAPRAS Standards for the Management of Open Fractures (2020): Degloving Injuries chapter; Arnez classification (JPRAS 2010) (DOI: 10.1093/med/9780198849360.003.0004).
What are the limitations of the Degloving Injury Management?
Known limitations include: Closed degloving (Morel-Lavallée) is often missed and can present late; No high-level guideline: based on BOA/BAPRAS standards, cohort studies and reviews; Clinical viability assessment is unreliable; necrosis can appear over days; Further operations are common. Individual patient factors may require deviation from these recommendations.
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