A degloving injury is a severe form of soft-tissue trauma characterized by the forceful separation of large sections of skin and underlying subcutaneous tissue from the body’s deeper structures. The mechanism involves extreme force that strips the tissue layers, often resulting in significant damage to blood vessels and nerves. Given the potential for massive blood loss, infection, and associated internal injuries, a degloving injury requires immediate, specialized medical intervention.
Understanding the Anatomy of a Degloving Injury
This traumatic separation occurs along the natural tissue planes, specifically between the superficial fascia (containing skin and fat) and the deep fascia that encases the muscles. The shearing force tears the delicate blood vessels and lymphatic channels that bridge these layers, compromising the blood supply to the detached skin. This anatomical disruption defines the severity of the injury and dictates the subsequent treatment approach.
Degloving injuries are generally categorized into two primary types based on the integrity of the overlying skin. An open degloving injury is the more visually obvious form, where the skin is completely torn or avulsed, leaving the underlying muscle, bone, or fascia exposed. This creates an immediate risk of contamination and infection.
The second type, known as a closed degloving injury, or a Morel-Lavallée lesion, occurs when the skin remains intact but is internally separated from the deep fascia. This separation creates a potential space that rapidly fills with blood, lymph fluid, and necrotic fat, forming a fluid collection. These closed lesions can often be missed in the initial trauma assessment, presenting as a fluctuating, mobile soft-tissue mass. The fluid collection acts as a breeding ground for bacteria and can lead to skin necrosis if the compromised blood supply is not restored.
Common Mechanisms of Injury
The forces that cause a degloving injury are typically high-energy and involve a combination of crushing and shearing actions. The injury occurs when a tangential force is applied to the skin, causing it to be stretched and pulled away from the firmer, fixed underlying tissues. This force overcomes the normal connective attachments between the skin and the muscle fascia.
Common scenarios involve motor vehicle accidents, such as a pedestrian being struck and dragged by a vehicle, where friction and crushing weight tear the soft tissues. Industrial accidents are also frequent causes, often resulting from machinery entanglement, like a limb being caught in a conveyor belt or a roller. A specific type of degloving, called a ring avulsion injury, occurs when a ring catches on an object, and the sudden pull strips the skin and soft tissue from the finger.
Immediate Emergency Stabilization
The immediate management of a degloving injury focuses on controlling life-threatening complications, particularly severe blood loss and shock. Emergency medical responders prioritize hemorrhage control, often by applying direct, firm pressure to the wound. In cases of massive, uncontrolled bleeding, a tourniquet may be temporarily applied above the injury site. Preventing shock involves keeping the patient warm, calm, and stationary while monitoring their vital signs.
For an open degloving injury, preventing infection is addressed by covering the wound with a clean cloth or sterile dressing. If any avulsed tissue is detached, it must be carefully preserved: wrap it in a clean material, place it in a sealed bag, and keep it cool without direct contact with ice. Rapid transport to a specialized trauma center is necessary for a comprehensive assessment of any associated injuries, such as underlying fractures or major vascular damage.
Surgical Reconstruction and Recovery
Definitive treatment for a degloving injury is surgical and centers on wound debridement and tissue reconstruction. The first step involves removing all non-viable, damaged, or contaminated tissue. This is essential to prevent systemic infection and prepare the wound bed for repair. For open injuries, the surgeon must decide on the viability of the avulsed skin flap.
If the degloved tissue is deemed non-viable, it is excised and may be prepared for use as a split-thickness skin graft. This involves shaving the skin into thin layers and applying them directly to the remaining healthy wound bed. When the soft tissue defect is large, or when deeper structures like bone, tendon, or joints are exposed, a more complex reconstruction is required using a tissue flap.
A flap involves transferring a section of skin, fat, and sometimes muscle, along with its dedicated blood vessels, from a healthy part of the body to the injury site. This provides a robust, well-vascularized tissue cover that is necessary for the underlying structures to heal properly. These flaps can be pedicled, remaining partially attached to their original site, or free flaps, where the blood vessels are surgically reconnected using microsurgery techniques.
Recovery is a long process, often involving multiple staged surgeries over weeks or months to achieve final coverage and contour. Rehabilitation, including physical therapy, is necessary to restore function, and patients may experience long-term issues such as chronic pain, numbness from nerve damage, and reduced mobility.