Degloving Injury

First aid for a degloving injury

1. Call 911 or your local emergency number.
2. Stop the bleeding: press firmly on the wound with a clean cloth or dressing. Keep pressure on. For life-threatening limb bleeding that pressure does not control, a tourniquet applied above the wound by someone trained can be lifesaving.
3. Do not remove the skin flap. If the skin is still partly attached, gently lay it back in its normal position without forcing it, and cover it with a clean, moist dressing.
4. Save any completely detached tissue or finger: wrap it in gauze moistened with saline or clean water, place it in a sealed plastic bag, and put the bag on ice. Do not put tissue directly on ice or in water.
5. Remove rings and jewelry from the injured limb if possible, before swelling makes it impossible. Do not attempt this if it causes more damage.
6. Raise the injured limb if possible, keep the person warm and lying down, and do not give food or drink in case surgery is needed.

What happens in a degloving injury

The skin and the fat beneath it (subcutaneous tissue) are attached to the underlying fascia, a tough layer covering the muscle, by small blood vessels and fibers. When a powerful shearing or rolling force acts on the skin, such as a car wheel passing over a leg, these connections tear. The skin loses its blood supply and may die even if it looks intact at first.

Types of degloving

Causes

• industrial machinery with rollers, belts or conveyors
• motorcycle and car crashes, especially being run over or dragged
• falls from height
• sports injuries, such as football or wrestling (closed degloving over the knee or thigh)
• rings catching on hooks, fences, basketball rims or truck doors
• animal attacks

Symptoms

• open degloving: a large wound with skin hanging loose or missing, heavy bleeding, exposed fat, muscle, tendon or bone
• closed degloving: a soft, fluctuant, sometimes enlarging swelling, bruising, reduced sensation over the skin, and skin that later darkens if its blood supply fails. It may be noticed only days or weeks after the injury
• ring avulsion: a finger stripped of skin, sometimes with loss of blood supply, numbness or exposed bone

Many degloving injuries come with fractures, a crush injury to the muscles, and injuries to other organs.

Diagnosis

• trauma assessment to find and treat life-threatening injuries first
• examination of the wound, blood supply, nerves and tendons
• X-rays and CT for fractures
• MRI or ultrasound to confirm closed degloving and measure the fluid collection
• assessment of skin viability, sometimes with special dye imaging during surgery

Treatment

Emergency and early surgery

• antibiotics and tetanus vaccination as needed
• thorough cleaning (irrigation) and debridement to remove dirt and dead tissue, often repeated over several operations
• reattaching the skin if it is healthy enough. Torn-off skin can sometimes be thinned and used as a skin graft
• negative pressure wound therapy (a wound vacuum) to prepare the wound for closure
• fixing fractures and repairing tendons, nerves and blood vessels

Reconstruction

• split-thickness skin grafts from another part of the body
• flap surgery: moving tissue with its own blood supply to cover bone, tendons or joints
• microsurgical replantation for completely detached fingers or scalp, when possible

Ring avulsion injuries

They are graded by how much damage there is. Mild cases need wound repair. Injuries with lost blood supply need microsurgery to reconnect vessels. Severe injuries with complete stripping may be best treated by amputation of the finger, which allows faster return to function.

Closed degloving (Morel-Lavallee lesion)

Small lesions may settle with compression. Larger or persistent ones are treated with drainage, sometimes with injection of a substance to seal the space (sclerodesis), or open surgery to clean out the cavity. Untreated lesions can become infected or form a chronic cyst.

Complications

• wound infection, including necrotizing fasciitis
• death of skin flaps (necrosis)
• compartment syndrome after crush injury
• loss of a finger or limb (amputation)
• scarring, contractures and stiffness
• nerve damage with numbness or pain
• long-term psychological effects, including post-traumatic stress disorder

Recovery

Recovery takes weeks to many months, depending on size and depth. Expect several operations, wound care visits and hand or physical therapy to restore movement and strength. Scar management with silicone, massage and pressure garments helps. Smoking slows healing and increases graft and flap failure, so stopping is important.

Frequently asked questions

What is a degloving injury?

A degloving injury is a severe type of avulsion in which skin and fat are torn away from the muscle, tendon or bone beneath, like removing a glove. It can be open, with visible stripped tissue, or closed, where the layers separate under intact skin.

What should I do if someone has a degloving injury?

Call 911, apply firm pressure to stop bleeding, gently lay any attached skin flap back into place and cover with a clean, moist dressing. Wrap completely detached tissue in moist gauze, seal it in a bag and place on ice. Keep the person warm and lying down.

What is a ring avulsion injury?

A ring avulsion happens when a ring catches on an object and the force strips the skin, and sometimes tendons, nerves and blood vessels, from the finger. Severity ranges from skin wounds to complete loss of the finger. Removing rings for manual work and sports prevents most cases.

What is a closed degloving injury?

A closed degloving injury, also called a Morel-Lavallee lesion, occurs when the skin and fat separate from the deeper layers under intact skin. Blood and fluid collect in the space, forming a soft swelling, often over the outer hip or thigh after a fall or crash.

Can skin reattach after degloving?

Sometimes. If the skin flap still has enough blood supply, surgeons can reattach it. If it does not, the skin may be thinned and reused as a graft, or replaced with grafts from elsewhere or flaps. Many injuries need several operations.