A 20 YEARS OLD MAN WITH SKIN LOSS AND SOFT

TISSUE LOSS ON CRURIS SINISTRA

NADIYA NUR HALIMA

G991903042

Supervisor :
dr. Amru Sungkar, SpB., SpBP-RE
Patient identity
• Name : Mr. MH
• Age : 20 yo
• Sex : Male
• Occupation : Student
• Address : Ponorogo, East Java
• MR number : 0147xxxx
• Admission date : Aug, 28th 2019
CHIEF COMPLAIN
Pain and open wound on left foot
Present illness
1 hour before, patient rode motorcycle and got hit by a motorcycle from behind. He
fell from the motorcycle to the left side. He was brought to RS Ponorogo. He was
fully conscious, there is no vomitus and seizure. He felt pain on his stomach, hip,
and left foot.
In the RS Ponorogo, he got infused, got X-ray examination, and his wound got
debridement.
The patient then get transferred to RSUD Dr Moewardi to get further therapy.
PAST HISTORY FAMILY HISTORY
• Drug Allergy : denied
Allergy : denied
• Hypertension : denied
Past Trauma : denied
• Diabetes Mellitus : denied
Inpatient : denied
• Heart Diseases : denied
Physical examination
Primary Survey
Airway : Clear
Breathing : RR 20x/minutes, symetric.
Circulation : BP 130/80, Pulse 82x/minutes.
Dissability : GCS E4V5M6
Exposure : Temperature : 37.0oC
Physical examination

Secondary Survey
Head : No abnormality Thorax : No abnormality
Eye : No abnormality Abdomen : see localized status
Ear : No abnormality
Genitourinaria : No Abnormality
Nose : No abnormality
Superior extremity : No abnormality
Mouth : No abnormality
Neck : No abnormality Inferior extremity : see localized status
Localized Status (Abdomen)
• Inspection : wound (-)
• Auscultation : decrease bowel sound
• Palpasion : pain (+), distended (+)
• Percussion: tymphani
Localized Status (extremity inferior)
• Inspection: Vulnus closed with sterile
gauze dressing, there is open wound
• Palpation: Pain (+) swelling (+)
• Movement: Blocked by pain
LABORATORIES
RESULT
ASSESMENT
• Skin Loss and Soft Tissue Loss post debridement
PLANNING
• IVFD RL 2600cc/24h
• Inj ranitidin 50 mg /12 h
• Inj paracetamol 1gr/8 h
• Pro negative pressure wound therapy (NPWT)
Literature Review
Definitions
Degloving injury defined as an avulsion of soft tissue,
in which an extensive portion of skin and ubcutaneous
tissue is detached from the underlying fascia, muscles,
or bone surface
The detachment of subcutaneous tissue with the
surroundings result in depletion of blood supply,
thereby increasing the risk of soft tissue dehiscence
and necrosis
Etiology
• These injuries can caused by high energy trauma, involving
heavy vehicles with little protection as the case of
motorcyclists
• Sometimes, traumatic shearing force or crush injury acting
on the skin surface can cause a degloving injury. Crush
injuries are the result of a body part being forcefully
compressed between 2 hard surfaces whereupon
compression of the muscle mass blocks the flow of blood and
oxygen to tissues resulting in ischemia
Classification
Pattern 1- Limited degloving with
abrasion/avulsion
• Loss of tissue as a result of the
abrasive force.
• Little undermining of the remaining
skin edges.
• Since the majority of these cases
occurred over bony prominences
(such as the malleoli) there is
exposed bone/ joints
 Classification
Pattern 2- Non circumferential degloving
• the majority of skin is still present either as a flap
or as an area of extensive undermining.
• The plane of avulsions is, in the main, confined to
a single layer (usually between the deep fascia
and the subcutaneous fat and skin)
Classification

Pattern 3- Circumferential single plane

degloving
Either open or closed circumferential
degloving of the integument confined to a
single plane (usually between the deep
fascia and the subcutaneous fat and skin)
Classification
Pattern 4- Circumferential multiplane
degloving
In addition to pattern 3 there is also a
breach of muscle groups and even
between muscle and periosteum
Clearly this pattern indicates a higher
degree of energy transfer to the limb.
 Classification
OPEN DEGLOVING INJURY
a soft tissue loss of variable extent together with avulsed
skin, subcutaneous tissue flaps from the underlying deep
tissues which is the hallmark of physical finding together
with overlying abrasion, ecchymosis or skin wound
Classification
CLOSED DEGLOVING INJURY
in closed or internal degloving injury the shearing forces
create a cavity which subsequently gets filled with
hematoma and liquefied fat. Such closed internal
degloving lesions usually develop over the greater
trochanter and are known as Morel-Lavallee lesions
In close degloving injury, appereance can be vary stage of
hematoma organization or degradation
 The Viability of Avulsed Flap
Determination of the viability of an avulsed flap is
difficult.
To evaluate flap viability, non-invasive techniques
currently available include:
1. ultrasound
2. laser Doppler
3. temperature monitoring
4. Transcutaneous oxygen monitoring
The Viability of Avulsed Flap
Flurescence dye intravenous
• After debridement and wound irrigation, fluorescein
dye were injected intravenously. After 15 minutes, the
avulsed skin flaps were examined.
• Non-fluorescent areas were marked under Wood’s
lamp illumination
• The marked area of the avulsed flap was defatted to
be used for FTSG.
• The fluorescent areas were sutured directly without
tension after minimal debridement. The non-
fluorescent areas were covered by defatted skin
 Imaging
• the diagnosis of closed DSTI is usually difficult and can be
missed on the initial clinical evaluation and require
radiological investigation for accurate diagnosis.
• USG: closed degloving injuries are usually hypoechoic
and well circumscribed
• CT: shows characteristic fluid-fluid levels resulting from
settling of blood products within the collection; a
capsule may be visible in chronic cases
• MRI: homogeneously hypointense on T1-weighted
sequences and hyperintense on T2-weighted sequence.
 Initial Treatment

The initial or immediate treatment of a complex injury of the

foot has several goals and can be divided into three
(overlapping) sub-phases:
1. prevention of progression of ischemia and necrosis,
2. prevention of infection,
3. consideration of salvage or amputation.
 Treatment
Free tissue transfer
If a single stage cover has to be provided, free tissue transfer
by the microvascular technique may be done.
The tissue that is transferred may be either an anterolateral
thigh flap, which is a skin flap, or a latissimus dorsi muscle
flap, which is covered with a skin graft. The disadvantage of
these procedures is the paucity of tissues that can be
transferred by this method, and the need for expertise in
microvascular surgery, to carry out the procedure.
 Treatment
full thickness skin graft followed by vacuum-assisted closure
• Allows firm fixation of the graft to the base, thereby
eliminating the shear forces and any potential space to
avoid seroma/haematoma formation.
• strong enough to hold the quilting sutures and will not be
torn off when shearing forces are applied
• leave a linear donor scar and require less aftercare than
mid-thickness grafts do.
 Treatment
Vacuum-assisted closure
To develop the wound bed for grafting gained wide
applicability which is directly applied to the wound
to promote granulation tissue formation and skin
grafting. VAC evacuates wound secretions and
blood, thus lowering the risk of seroma, hematoma
and infection and shortening the time necessary for
engraftment
Sources
• Akhtar, S., & Hameed, A. (2006). Versatility of the sural fasciocutaneous flap in the coverage of lower third leg and hind foot defects. Journal of Plastic, Reconstructive & Aesthetic
Surgery, 59(8), 839–845.doi:10.1016/j.bjps.2005.12.009
• Altun, S., Orbay, H., Ekinci, M., Cetinbas, A., Bal, A., Arpaci, E., & Okur, M. İ. (2017). A comparison of rat degloving injury models. Acta orthopaedica et traumatologica turcica,
51(4), 308–312. doi:10.1016/j.aott.2017.03.007
• Andres, T., von Lübken, F., Friemert, B., & Achatz, G. (2016). Vacuum-Assisted Closure in the Management of Degloving Soft Tissue Injury: A Case Report. The Journal of Foot and
Ankle Surgery, 55(4), 852–856.doi:10.1053/j.jfas.2015.12.002
• Arnez, Z.M., Khan, U., Tyler, M.p. (2010). Classification of soft-tissue degloving in limb trauma. Journal of Plastic, Reconstructive & Aesthetic Surgery , 63(11), 1865 - 1869
• Chen, Y., & Liu, L. (2016). Clinical analysis of 54 cases of large area soft tissue avulsion in the lower limb. Chinese journal of traumatology = Zhonghua chuang shang za zhi, 19(6),
337-341. H
• Dini M1, Quercioli F., Mori A. Vacuum-assisted closure, dermal regeneration template and degloved cryopreserved skin as useful tools in subtotal degloving of the lower limb.
Injury. 2012;43:957–959.
• Faisham, W., Azman, W., Muzaffar, T., Muslim, D., Azhar, A., & Yahya, M. (2012). Traumatic hemipelvectomy with free gluteus maximus fillet flap covers: a case report. Malaysian
orthopaedic journal, 6(3), 37–39. doi:10.5704/MOJ.1207.002
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Heel. Cureus, 9(6), e1331. doi:10.7759/cureus.1331
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THANK YOU