A hand degloving injury is a severe form of trauma where a large section of skin and underlying soft tissue is forcibly ripped or torn away from the deeper structures of the hand. The term “degloving” originates from the injury’s appearance, which resembles removing a glove from a hand or finger. This severe soft-tissue avulsion is considered a traumatic emergency because it compromises the protective barrier of the skin. Immediate medical intervention is necessary to address the extensive tissue damage and prevent potential long-term disability and loss of function.
The Anatomy and Mechanism of Degloving Injuries
This traumatic separation occurs when a strong, tangential shearing force is applied to the hand, peeling the superficial layers away from the deeper, fixed structures. Degloving involves the forceful detachment of the skin and fat layers from the deep fascia that covers the muscles and bones. This mechanism is damaging because the skin and fat contain the small blood vessels and nerves that provide nourishment. When the tissues are sheared apart, these vessels are ruptured, disrupting the blood supply and causing the separated skin to quickly lose oxygen and nutrients, leading to tissue death. The separation typically occurs just above the deep fascia, though damage to underlying muscle, tendons, and bone is common in high-energy trauma.
Common Causes and Classification of Hand Degloving
Degloving injuries are typically caused by accidents involving powerful mechanical or rotational forces. Workplace incidents, particularly those involving industrial machinery like rollers, conveyor belts, or gears, are frequent causes of this injury. High-energy motor vehicle accidents, where a limb is crushed or dragged, also commonly result in the necessary shearing forces.
A distinct and common cause for finger degloving is a ring avulsion injury, where a ring caught on a fixed object strips the soft tissue from the finger. Degloving injuries are broadly categorized into two types based on the integrity of the skin. Open degloving is where the skin is completely torn off or left hanging as an exposed flap, leaving deeper tissues like tendons and bone visible. Closed degloving occurs when the skin remains intact but is separated internally from the underlying fascia, creating a cavity that fills with blood and fluid. The overlying skin in a closed injury is at high risk of necrosis because its vital blood supply has been disconnected, even though it appears externally undamaged.
Emergency Medical Response and Surgical Reconstruction
The initial emergency response focuses on stabilizing the patient, managing blood loss, and assessing associated injuries like fractures. For the hand injury, the priority is to salvage viable tissue and prepare the wound for surgical reconstruction. If the degloved skin or a finger is completely detached, it must be carefully preserved in a sterile, cool, and moist environment, as replantation may be the best option.
Surgical reconstruction aims to provide a durable, pliable, and sensitive skin cover over exposed structures to prevent infection and restore function. If the tissue is clean and minimally crushed, the first choice is microsurgical replantation and revascularization of the original skin flap. This complex procedure involves repairing the severed blood vessels to restore circulation, offering the best potential cosmetic and functional result.
If the original tissue is too damaged or contaminated, the surgeon must choose an alternative method. Skin grafting involves transplanting a thin layer of skin from another part of the body onto the wound bed. Simple grafts are often inadequate for the hand because they provide poor padding over tendons and joints and lack the necessary thickness for functional areas.
When extensive soft tissue loss exposes bone and tendons, complex tissue transfer procedures, known as flaps, are required. A flap involves transferring skin, fat, and sometimes muscle from a distant site while keeping its blood supply intact. These include pedicled flaps, which remain temporarily attached to the donor site, or free flaps, where the tissue is detached and its blood vessels are microscopically reconnected to the hand’s vessels. Amputation is a measure of last resort, considered only when damage is so severe that reconstruction is impossible or when life-threatening infection cannot be controlled.
Prognosis and Long-Term Functional Recovery
Recovery from a hand degloving injury is typically a protracted and demanding process, often extending over many months or even years. The long-term prognosis depends heavily on the extent of the initial damage, the success of the surgical reconstruction, and the patient’s commitment to rehabilitation. Even after successful wound closure, the reconstructed tissue, especially flaps, may initially be bulky and lack the sensation of the original skin.
Physical and occupational therapy (PT/OT) is a mandatory component of recovery to prevent joint stiffness and maximize the regained mobility and strength. Therapists guide patients through exercises designed to restore the fine motor control and dexterity necessary for daily activities. Long-term complications are common due to the initial severity of the trauma and the nature of the reconstructive surgery.
The shearing mechanism frequently causes permanent nerve damage, leading to chronic loss of protective sensation or persistent neuropathic pain. Stiffness in the joints and a significantly reduced range of motion are expected outcomes, even with diligent therapy. Many patients require secondary surgical procedures, such as flap thinning or scar revision, to improve both the function and the appearance of the hand years after the initial injury.