Sukmana A

Hidajat N. N.

Chaidir R

Department of Orthopaedic and Traumatology Faculty of Medicine Padjadjaran University

Hasan Sadikin Hospital Bandung

ABDOMINAL FLAP FOR DEGLOVING LESSIONS OF THE HAND (A CASE REPORT)

Hand deglovingHand degloving

Incidence Incidence – Hongkong : Hand injury 600 / 100.000Hongkong : Hand injury 600 / 100.000

Hand degloving : 1,4 %Hand degloving : 1,4 %

– Indonesia ???Indonesia ??? Prognosis : doubtful Prognosis : doubtful Result to this patient :Result to this patient :

– Skin coverage : goodSkin coverage : good– Hand function : Hand function : medical rehabilitation medical rehabilitation

Patient ProfilePatient ProfilePatient ProfilePatient Profile

CC : Degloving of the right hand CC : Degloving of the right hand

Three hours before admission, the Three hours before admission, the patient’s hand entraped in a textile patient’s hand entraped in a textile machinemachine

wounded at the right handwounded at the right hand Degloving of the skin of the second to Degloving of the skin of the second to

fifth digitsfifth digits Bone , nerve and tendon exposureBone , nerve and tendon exposure No medication or first aid before No medication or first aid before

hospitalized hospitalized

History

Miss L 26 yo Employee of a textile factory Right handed

a/r right handa/r right hand ::

LookLook : wound (+), skin degloving at plantar : wound (+), skin degloving at plantar and dorsal aspect of the second to fifth and dorsal aspect of the second to fifth finger at the level MCP joint with tendon finger at the level MCP joint with tendon and bone ekspos (+), and bone ekspos (+),

amputee : stuck in the machineamputee : stuck in the machine

FeelFeel : tenderness (+), : tenderness (+),

Movement : motion of the MCP,PIP, DIP joint ; Movement : motion of the MCP,PIP, DIP joint ; limited due to painlimited due to pain

Physical examination

Laboratory Finding

X Ray

X ray right hand : fracture line (-), dislocation (-)

Hemoglobin : 11,8 g/dl

Lekocyte : 9100/mm3

Hematocrite : 35%

Trombocyte : 255.000/mm3

Case ReportCase Report

Skin degloving at the second to fifth finger Skin degloving at the second to fifth finger

or the right handor the right hand

Debridement Debridement randon pattern abdominal Flap randon pattern abdominal Flap

Cefotaxim 2 x 1 gr (iv)Cefotaxim 2 x 1 gr (iv)

gentamicyn 2 x 1 ampgentamicyn 2 x 1 amp

Ranitidin 2 x 1 ampRanitidin 2 x 1 amp

Aspilet 2 x 1 p. o Aspilet 2 x 1 p. o

Pain program : ketorolak : 1 amp + tramadol 1 amp / RL 20 Pain program : ketorolak : 1 amp + tramadol 1 amp / RL 20

gtt/menitgtt/menit

Hand warmingHand warming

Diagnosed

Treatment

Size of skin defect Size of skin defect – Random pattern Random pattern

abdominal flapabdominal flap Problem : Problem : necrotic of necrotic of

the distal of the digits the distal of the digits at the volar site 1 x at the volar site 1 x 0,5 cm (POD III)0,5 cm (POD III)– Aspilet 2 x 1 Aspilet 2 x 1

First Operation

Second operationSecond operation

After 19 days from After 19 days from the first operationthe first operation

Release flapRelease flap Problem :Problem :

– Necrotic tissue at Necrotic tissue at the volar aspect (+) the volar aspect (+) (POD II)(POD II)

– Wet wound (+)Wet wound (+)

Third operationThird operation

25 days after the 25 days after the second operationsecond operation

Problem : Problem : secondary secondary infection; Pus (+) infection; Pus (+) at the distal hand , at the distal hand , necrotic tissue (+), necrotic tissue (+), bone expose digital bone expose digital II – IV (+)II – IV (+)

Debridement Debridement Disarticulation DIP Disarticulation DIP

joint digiti II – IV joint digiti II – IV manus dx.manus dx.

Fourth operationFourth operation

42 days after the third operation42 days after the third operation Problem : protruding bone digiti II & III at the end of the Problem : protruding bone digiti II & III at the end of the

stumpstump– DebridementDebridement– Osteotomy of the protruding boneOsteotomy of the protruding bone– Separation interdigiti III - IVSeparation interdigiti III - IV– De fatting De fatting – FTSGFTSG

Fifth operationFifth operation

35 day after the 435 day after the 4thth operation operation

Problem : pus (+) Problem : pus (+) at interdigit II – IIIat interdigit II – III– DebridementDebridement– Separation Separation

interdigit II – III interdigit II – III – Defatting Defatting – FTSG for the defect FTSG for the defect

from abdomen from abdomen

Sixth operationSixth operation

52 days after the 552 days after the 5thth operation operation Separation of the IV – V fingersSeparation of the IV – V fingers De fattingDe fatting FTSG for the defect from the abdomenFTSG for the defect from the abdomen Post op care ; cefotaxim 2 x 1 gr, aspirin 2 x 50 mg, ranitidin 2 x 1 Post op care ; cefotaxim 2 x 1 gr, aspirin 2 x 50 mg, ranitidin 2 x 1

amp, ketorolak 2 x 1 amp, amp, ketorolak 2 x 1 amp, X – ray after opX – ray after op

The Latest Follow-upThe Latest Follow-upThe Latest Follow-upThe Latest Follow-up

4 months

Degloving of the handDegloving of the hand

Orthopaedic dictionary : Orthopaedic dictionary :

An injury of the hand or foot that An injury of the hand or foot that characteristically in avulsion of skin characteristically in avulsion of skin area with Important structures such area with Important structures such as tendons, nerves, and bones are as tendons, nerves, and bones are

exposed and will necrose if not exposed and will necrose if not covered adequately covered adequately

EtiologyEtiology

Campbell’s :Campbell’s :

– Trapped on a moving machineTrapped on a moving machine– Human biteHuman bite– Tornado missileTornado missile– AugersAugers– War woundWar wound– High velocity missile woundHigh velocity missile wound

Diagnose Diagnose

X – ray :X – ray :– fracture fracture – dislocation or dislocation or – foreign bodyforeign body

Laboratory Laboratory – Blood status for surgeryBlood status for surgery

Treatment Treatment

Campbell’s : Campbell’s :

the purpose of treatment is to the purpose of treatment is to – restore its functionrestore its function

It is necessary to : It is necessary to : – prevent infection prevent infection – salvage injured parts salvage injured parts – and promote primary healingand promote primary healing

TreatmentTreatment

As indicatedAs indicated– AntibioticAntibiotic– SedativeSedative– Tetanus prophylaxisTetanus prophylaxis– Blood transfusionBlood transfusion

Skin closureSkin closure– Direct sutureDirect suture– Skin graftsSkin grafts– Skin flapSkin flap

Abdominal FlapAbdominal Flap

Orthopaedic dictionary : Orthopaedic dictionary : A type of distant flap graft used to provide A type of distant flap graft used to provide

subcutaneous tissue for coverage of deep subcutaneous tissue for coverage of deep soft tissue defectsoft tissue defect

– Same side : a distal flap based; epigastric Same side : a distal flap based; epigastric vessel or superficial circumflex iliac arteryvessel or superficial circumflex iliac artery

– Opposite side : a proximal flap based; thoraco - Opposite side : a proximal flap based; thoraco - epigastric vesselepigastric vessel SupraumbilicalSupraumbilical Avoid the fat storage areasAvoid the fat storage areas

Technique : Campbell’sTechnique : Campbell’s

Make a pattern on a sterile paperMake a pattern on a sterile paper Outline the pattern on the abdomenOutline the pattern on the abdomen Raise the skin flap of the desired size and Raise the skin flap of the desired size and

thicknessthickness Maintain hemostatisMaintain hemostatis Close the defect of the donorClose the defect of the donor Apply the flap over the entire defectApply the flap over the entire defect Suture the edges of the flap to those of Suture the edges of the flap to those of

the defectthe defect

Technique Technique

Place a strip of non adhering gauzePlace a strip of non adhering gauze Prevent kinking, tension, or rotationPrevent kinking, tension, or rotation Bandage around the trunk to support Bandage around the trunk to support

the armthe arm Accessible inspectionAccessible inspection Steinmann pin if necessary Steinmann pin if necessary

After TreatmentAfter Treatment

Inspection in the first 48 hoursInspection in the first 48 hours Tension ?, torsion?, hematome?, too Tension ?, torsion?, hematome?, too

tight sutures?tight sutures? Necrotic ; excised Necrotic ; excised STSG STSG Avoid odor Avoid odor infection infection Flap detachment ; 3 weeks, in Flap detachment ; 3 weeks, in

children ; 2 weeks children ; 2 weeks

Medical Rehabilitation Medical Rehabilitation ProgramProgram

Hand function : oral hygiene, Hand function : oral hygiene, Dressing, Bathing, Grooming, etcDressing, Bathing, Grooming, etc

Sensory : Hyper/Hypo/ un ; esthesia, Sensory : Hyper/Hypo/ un ; esthesia, sensitize or de sensitize sensitize or de sensitize

Vocational : writing etc. Vocational : writing etc.

OutcomeOutcome

consideration :consideration :– AttachmentAttachment– Multiple stages operation Multiple stages operation “the “the

patient must be very patient” patient must be very patient” (cooperative)(cooperative)

– Prolonged hospital stayProlonged hospital stay– Doubtful resultDoubtful result

Very Important to inform the patientVery Important to inform the patient

DiscussionDiscussion DiscussionDiscussion

Female, 26 yo

Employee of a factory

Trapped hand on the textile machine

Hand degloving

Abdominal flap

Rehabilitation

Separation

DASH Questionnaire

ConclusionsConclusions ConclusionsConclusions

Hand trapping on a moving machine can Hand trapping on a moving machine can cause degloving of the handcause degloving of the hand

To close a wide defect , abdominal flap may To close a wide defect , abdominal flap may be sufficientbe sufficient

HATUR HATUR

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