Degloving refers to a severe and life-altering traumatic injury where a large section of skin and underlying soft tissue are forcibly torn away from the body’s deeper structures, such as muscle and fascia. This injury is frequently observed in the lower extremities, specifically the leg, due to the mechanisms of trauma involved. It represents a major soft-tissue avulsion requiring immediate, specialized medical intervention because of the potential for massive blood loss and extensive tissue death. This article explains the nature of this trauma, its classification, and the complex treatment and recovery process required for a degloved leg.
Understanding Degloving Trauma
A degloving injury occurs when a high-energy impact, often a crushing or shearing force, acts tangentially across the skin surface. This force causes the skin and the layer of subcutaneous fat to separate violently from the deep layer of connective tissue, known as the fascia, which covers the muscle. This mechanism is similar to peeling a glove off a hand. The lower leg is highly susceptible to degloving because of the limited soft tissue padding over the bone.
These traumas result from high-velocity accidents, most commonly motor vehicle collisions, motorcycle accidents, or incidents involving heavy industrial or farm machinery. In these scenarios, the limb may be caught and pulled or run over by a tire, creating the necessary shear force to strip the tissue layers apart. This separation immediately disrupts the perforating blood vessels that supply the skin and fat, severely compromising the viability of the avulsed tissue flap.
Categories of Injury Severity
Degloving injuries are categorized into two primary types based on whether the skin remains intact, which guides the initial treatment approach. Open degloving occurs when the skin is completely or partially torn away, leaving the underlying muscle, bone, or tendons exposed. The avulsed skin flap may be completely detached or remain partially connected by a small bridge of tissue.
The second type is closed degloving, also known as a Morel-Lavallée lesion. Here, the skin surface remains intact, but the internal layers have separated from the deep fascia. This separation creates a cavity that quickly fills with blood, lymph fluid, and liquefied fat, forming a large, deep hematoma. Both types are serious because the detachment deprives the tissue of its blood supply, leading to a high risk of tissue death, or necrosis.
Immediate Emergency Stabilization
The immediate medical response focuses on stabilizing the patient and mitigating the trauma. The first priority is controlling severe hemorrhage using direct pressure or, if necessary, a tourniquet placed above the injury site. Due to significant blood loss, assessing the patient for signs of traumatic shock, such as rapid pulse and pale skin, is essential.
If any tissue has been completely torn off, emergency personnel must attempt to preserve it for potential surgical use. The detached tissue should be carefully wrapped in a clean, moist dressing and kept cool, but never placed directly on ice, to maximize its chances of survival. Once stabilized, the patient moves to the emergency department, where doctors assess the full extent of the damage, including potential fractures, to prepare for definitive surgical intervention.
Surgical Repair and Long-Term Rehabilitation
Definitive treatment for a degloved leg is complex and almost always involves reconstructive surgery to cover the exposed area and restore function. The surgical team first performs a thorough debridement, which involves meticulously cleaning the wound and removing all non-viable, contaminated, or crushed tissue. This step is performed immediately to prevent severe infection, a major complication risk in open wounds.
The avulsed skin flap often cannot be successfully reattached because its blood supply is irreparably damaged, leading to necrosis. Surgeons frequently use the degloved skin after it has been thinned and processed into a specialized full-thickness skin graft to cover the wound. If the injury is extensive or involves deep structures like bone or tendon, a more complex reconstructive procedure called a free-flap may be required. This involves transferring a block of healthy skin, fat, and muscle from a donor site on the patient’s body to the leg, using microsurgery to connect the blood supply.
The recovery process following these procedures is lengthy, often requiring multiple surgeries and an extended hospital stay. Long-term rehabilitation is necessary to regain mobility and function, including intensive physical therapy to manage scarring and prevent joint contractures. Patients must be monitored for delayed complications, such as chronic pain, nerve damage, or persistent fluid collection, which can continue for months or years after the initial trauma.