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Full-thickness skin replacement after traumatic avulsion

1966; Elsevier BV; Volume: 19; Linguagem: Inglês

10.1016/s0007-1226(66)80048-6

1465-3087

B.V.M. Corps, Martin Littlewood,

Bone fractures and treatments

THE reports in the literature of skin replacement after traumatic avulsion suggest that the full-thickness skin of the avulsed specimen is best discarded and that replacement should be by split-thickness skin grafts.T h e writers wish to present an extreme case of traumatic avulsion of skin from a limb to show that this is not always true. CASE REPORTSCase I .--A 49-year-old miner was admitted to the Plastic Surgery Unit of Whiston Hospital in October I962, three hours after injury.His right hand and forearm had become caught in a conveyor belt in a nearby coal-mine and he suffered a degloving injury of the skin and subcutaneous tissue from the upper third of his right arm, to the heads of the metacarpals on the dorsal aspect of the hand, and to the wrist on the volar aspect (Fig. I).There was considerable damage to the deep fascia and to the biceps and brachialis muscles and the extensor tendons on the dorsum of the hand were exposed.After intravenous plasma and blood he was taken to the operating theatre later the same day, when the extent of the injury was determined under general ana:sthesia.The degloved skin, which was still attached only on the ulnar border of the hand, was removed, leaving enough skin to supply a viable flap which covered the exposed extensor tendons over the metacarpal heads.The operating time was devoted to a debridement of the limb, and a considerable portion of the biceps muscle, and crushed and lacerated deep fascia was removed and split.The limb was then dressed with bulky absorbent dressings and a plaster-of-Paris cast applied and the patient returned to the ward.The avulsed skin and subcutaneous tissue of the forearm were examined and it was found that only the edges, where crushing had devitalised the skin, were fit for sacrifice, the rest of the tissue, which had been removed by a shearing force at the level of the deep fascia, was thought to be viable and so, after the patient had returned to bed, an hour was spent defatting the avulsed specimen and converting it into a giant full-thickness graft.This was then refrigerated at 4 ° C.Four days later, under general anaesthesia, the dressings were removed in the operating theatre and it was found that the surface was free of all dead tissue and ha:mostasis was complete.The previously prepared full-thickness graft was applied with the seam longitudinally disposed along the ulnar border and secured by interrupted silk sutures.Portions of the limb over the biceps, ulnar part of the dorsum of the hand, and the hypothenar eminence, where full-thickness skin graft cover could not be achieved, were covered with split-thickness grafts from the thigh.The arm was then immobilised and elevated.At the first dressings in one week all the grafts had " taken," with the exception of a small area over the olecranon, which was covered secondarily with refrigerated split-skin grafts.His subsequent rehabilitation was slow, the function of the elbow, wrist, and hand took one year to regain, and in October 1963 he returned to a light job at the colliery.Eight months later, twenty months after the injury, he was doing a full day's normal work on the surface at the colliery and has continued to do so since.The range of movement at his elbow, wrist, and radio-ulnar joints is full and he has normal power at these joints.He has some loss of power grip, due to damage to the