What Kind of Injury Can Cause Penis Degloving?
Introduction
Full hand skin degloving injury is associated with low morbidity in clinic; however, it remains a challenge in the surgical treatment of easily. Information technology is often induced past huge shear strength (Figure 1) and is characterized by the injury features of irregular wound margin and severe contusion. Mostly, the avulsed skin, blood vessel, nerve, tendon, bone and articulation are not on the aforementioned aeroplane. There is severe intimal contusion, as well as artery and nerve avulsion in some cases.ane–iv Therefore, the surgical handling and rehabilitation of such diseases take posed a dandy challenge to surgeons.
  | Figure 1 Total paw peel degloving injury caused by roller. |
Numerous scholars have long been trying many methods to repair the total manus skin degloving injury; however, the clinical demands tin can hardly exist satisfied. Some new methods and technologies have emerged recently with the rapid development of microsurgery, among which treating total manus skin degloving injury with abdominal flap is simple and safe. Nevertheless, information technology is associated with postoperative flap swelling, which volition lead to unsatisfying paw function.five,6 Moreover, anterolateral thigh flap combined with toe transplantation can too be applied in reconstructing the injured paw, but it volition requite rise to unfavorable hand function and advent recovery.7 Çoban et al8 had reported a instance with multiple digital degloving injuries treated with distal-based reverse forearm radial perforator flap, which represented a non-microsurgical treatment option. Every bit a outcome, avulsed pare in situ replantation is the preferred option for treating full hand skin degloving injury, which is linked with the superiorities of small wound, proficient paw appearance, no obvious scar contracture, elasticity, favorable sensation, and high patient acceptability.9 Briefly, such a technology has carried out vascular anastomosis through microsurgery, which oftentimes requires vascular transplantation in the presence of vascular defect.
In this report, a patient with full paw skin degloving injury successfully treated through avulsed skin in situ replantation is reported. To exist specific, the superficial vein of forearm was transplanted intraoperatively; in the concurrently, the arteria digitalis communis and ulnar artery were anastomosed. Later on surgery, the patient was followed-up for 2 years, and satisfactory efficacy and manus part had been attained, which were rarely reported in previous literature. Thus, the current study aimed to innovate our successful experience in this instance.
Ideals statement
This study was canonical by the Medical Ethical Committee of the Wuxi No 9 People's Infirmary Affiliated to Soochow University. Written informed consent was obtained from the participant. The patient agreed to employ his photos and data to this medical research and permit his photos to be published in the journal of Therapeutic and Clinical Run a risk Management.
Case report
A 35-twelvemonth-onetime man presented with correct hand peel degloving injury due to crushing of printing machine. Skin degloving avulsion was seen in the right hand from the distal forearm to fingertip, while the thumb, maniphalanx, articulation, tendon, nerve and intrinsic muscles remained relatively intact. Moreover, the degloved pare was basically intact; blood supply was available for the five fingers. The broken end of the common palmar digital arteries for the five fingers is located in the palm cantankerous grain, while the vein of back of hand ruptured at the site 2 cm abroad from the carpal joint. Avulsion on hand back generally began from the superficial layer of deep fascia, while avulsion on the palm side started from the superficial layer of palmar aponeurosis. In improver, peel avulsion on the fingers started from the superficial layer of flexor digital tendon sheath and extensor tendon (Effigy 2A). Debridement and vessel-transplanting replantation were conducted in the patient under brachial plexus cake, and six-hand veins were anastomosed intraoperatively (Figure 2B). Specifically, the superficial vein of forearm was transplanted, and the ruptured 2d to 5th arteria digitalis communis was anastomosed with ulnar avenue, while the commencement to second arteria digitalis communis was anastomosed with radial artery (Figure 2C). Finally, the palmar and dorsal hand skin was slightly thinned, followed by pressure dressing. The whole performance time was ~7 h, and the surgery was operated by two groups of surgeons with over ten years of microsurgery experience.
 | Effigy 2 Total mitt skin degloving injury. |
The flap had healed postoperatively, no sign of flap necrosis was seen, and the swelling had lasted for half a month. In add-on, partial necrosis of palm skin was observed, which survived after change in dressing, and no catastrophic complication was observed. Rehabilitation preparation was initiated ten days subsequently surgery, and the swelling had gradually disappeared thereafter. The patient paid a subsequent visit 2 years postoperatively, and favorable texture of palmar and dorsal hand skin could be observed (Figure 3A and B). The final range of motion (ROM) is shown beneath. Agile flexion of the get-go metacarpophalangeal joint of thumb was ~sixty°, active flexion of the third to fifth metacarpophalangeal joints was ~xc°, and active flexion of second to fifth proximal interphalangeal point was ~90°. Moreover, favorable finger appearance could be attained, pollex abduction and digital opposition function had been restored, and satisfactory recovery of finger flexion and extension function had been achieved (Effigy 3C–F). We had anatomized the digital nerves for the v fingers intraoperatively, and the sensory function of these fingers had been restored to Grades S2–S3.
 | Figure 3 Appearance and function afterwards surgery. |
Word
Total mitt skin degloving injury refers to degloving avulsion of mitt skin and soft tissue as a event of external violence and roller crushing, which can be attributed to the protective conditional reflex and strong retraction of the torso. Such an injury is characteristic of irregular wound margin and severe contusion. Generally, the avulsed pare, blood vessel, nervus, tendon, bone and articulation are not located on the same plane. In addition, severe intimal contusion can be observed in some cases, along with avenue and nervus avulsion.10 Typically, the peel superficial vein will exist injured later total hand skin degloving injury. In the concurrently, part of the pare is still connected to the finger root or proximal phalanx or tendon. Yet, the proper palmar digital artery is frequently subject to injury due to traction, which may manifest as vascular rupture or embolism. Therefore, it is completely possible to reconstruct the blood supply for the fingers once the distal and proximal ends of rupture can exist found. Hand peel degloving injury is different from severed finger replantation, since cases undergoing severed finger replantation generally have favorable finger blood apportionment and integrity of the degloving skin with no obvious avulsion. In contrast, cases with total paw skin degloving injury by and large endure from incomplete skin integrity and severe contusion. Therefore, the peel condition should be determined first of all when treating total manus skin degloving injury using the vascular anastomosis in situ replantation technique. Mistaken judgment volition issue in not only replanted skin necrosis but also finger necrosis in some severe cases. Nevertheless, information technology is not always like shooting fish in a barrel for accurate judgment of peel condition, which mainly depends on the feel of the operator.xi
It is of high risk to treat total paw peel degloving injury with vascular anastomosis replantation. Nonetheless, information technology can atomic number 82 to superior effects over other procedures in terms of hand advent and function, as long equally the skin has completely survived. In addition, such a surgery requires no massive skin donor site or additional donor sites, making it more easily acceptable among patients. Our experience from the successful surgical treatment for this case is that, commencement, thorough debridement is disquisitional, since infection will inevitably touch skin survival and vascular patency. Particularly, a second debridement is necessary under microscope for severely polluted patients. Second, thorough intraoperative hemostasis should be performed, the drainage tube should exist placed subcutaneously immediately after surgery, and smooth drainage should be guaranteed. Meanwhile, advisable palmar and dorsal compression tin can avoid the formation of subcutaneous hematoma, which may affect peel survival or pb to infection. Typically, the pressure is appropriate not to compress the anastomosed vessel. Third, veins in the margin of palmar and dorsal hand avulsed skin should be anastomosed as far equally possible, so equally to reconstruct the venous return for the avulsed skin, which is ane of the essential measures guaranteeing the survival of palmar and dorsal paw skin. Quaternary, avulsed skin contusion should be carefully determined intraoperatively, and replantation should exist avoided in cases with severe contusion, since non-survival of skin will definitely induce finger necrosis. Fifth, the arterial arch should be reconstructed in patients with superficial palmar arch avulsion and rupture in palm. Notably, the forearm dorsal reticular vein tin be transplanted for reconstruction of the vascular defect, which is beneficial for the reconstruction of finger blood supply. Importantly, the problem of hand venous render pathway should be taken into account in the instance of venous transplantation, and attention should be paid not to cut the major reflux vein. Notably, forearm dorsal superficial vein is appropriate for transplantation nether this condition. As is shown in our case, the forearm dorsal superficial vein is transplanted, and the ruptured second to fifth arteria digitalis communis is anastomosed with ulnar artery, which facilitates the smooth recovery of hand appearance and part after replantation. Terminal simply not the least, part of skin margin stitch can be removed to gently squeeze out the hematocele or blood clot, when subcutaneous hematocele is found in palm and dorsal paw during postoperative dressing change, followed by pressure dressing and fixation.
The integrity of vascular network should be ensured preoperatively, which is benign for the surgical planning and vascular reconstruction. In our instance, we have overturned the avulsed skin before surgery and discovered that the broken stop of the common palmar digital artery for the five fingers is located in the palm cross grain (Figure 2C). Thus, the arterial broken end for vascular grafting and anastomosis can therefore be found. Undoubtedly, blood supply is a fundamental observational alphabetize after skin replantation, which can be judged based on the post-obit aspects: ane) Observation of the replanted skin color: skin color is the nigh easily observed and nigh reliable objective index. Even so, the interfering factors should be avoided in observation, such as the influence of low-cal and skin disinfector. Typically, the hot lamp can be deviated or turned off, so as to detect the flap color under natural low-cal. Moreover, no disinfector such as iodine can be applied in coating the flap. Typically, a bright ruby-red color of flap indicates favorable blood supply, while a light or pale flap color is suspicious of arterial spasm or embolism. Meanwhile, a cyanosis or dark red colour of flap reveals obstruction of venous reflux. 2) Capillary filling test: in this, the flap is gently compressed using the pinkie pulp or cotton swab. Under general condition, the compressed flap is pale, which becomes reddish 1–2 s subsequently compression removal. Information technology is noteworthy that the slow or disappeared filling reaction suggests insufficient or creased arterial claret supply, while the rapid filling indicates great possibilities of venous crunch. 3) Measuring skin temperature at regular fourth dimension and location: skin temperature should exist measured every hr within 3 days after surgery, which is then compared with that in the healthy side. Importantly, the location for measuring skin temperature should be fixed. Later on, peel temperature can exist measured every 2 h on day 3 to mean solar day v and every four h on day six and day vii. Temperature volition not exist measured afterwards 7 days if no aberration occurs. All the same, in the case of claret apportionment disorder of flap, the pare temperature should be measured every hour. Specifically, the flap temperature lower than the good for you side past >3°C accompanying with colour change usually reveals blood circulation disorder, which requires urgent management. 4) Flap swelling degree: the swelling degree tin be determined according to the plica. Commonly, plica can be observed in full and rubberband flap, which disappears in the presence of excessive tension, forth with cyanosis skin colour, bright swelling, and subcutaneous vesicle. Mild inflammatory response and mild swelling can be observed after normal skin replantation, which may result from surgical trauma and will gradually fade away 3–7 days after surgery. However, the dressing should exist checked to see whether it is likewise tight. Meanwhile, whether there is subcutaneous hematoma pinch should also be checked if flap swelling is observed. Under such circumstances, the run up can be intermittently removed to eliminate the hematocele and hematoma.
Conclusion
Repairing the total manus skin degloving injury with avulsed skin in situ replantation through vascular transplantation tin can completely repair the paw wound, in the meantime of attaining more favorable manus appearance and function. It tin reduce injury in the donor site, shorten the course of therapy, and alleviate patient sufferings, thus attenuating the concrete and mental burdens on patients. Therefore, it is an alternative method to treat total mitt peel degloving injury.
Disclosure
The authors report no conflicts of interest in this work.
References
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