Arch Hand Microsurg.  2022 Sep;27(3):234-239. 10.12790/ahm.22.0028.

Saving a large volume of soft tissue by using an untailored composite graft after total degloving amputation of the hand: a case report

• Lee KJ
• Lee JY
• Koh SH
• Kim JS
• Roh SY
• Lee DC

• KMID: 2532740
• DOI: http://doi.org/10.12790/ahm.22.0028

Abstract

Total degloving amputations present surgeons with unique challenges to preserve function and prevent amputation of the digits. Obviously, the replantation of avulsed skin is the best option; however, there are situations in which vascular networks are severely contused, making it difficult to restore the circulation, due to the crushing mechanism of injury. As an alternative, defatted or meshed skin grafts from the avulsed skin have been proposed. However, those options have not been proven to guarantee viable digits. Moreover, the application of thinned skin grafts usually results in cosmetically and functionally unsatisfactory outcomes due to the lack of sufficient tissue volume. We present a case in which we successfully saved a large volume of the amputated stump with minimal digit amputation by performing a composite graft of the untailored (i.e., without defatting or meshing) avulsed skin on a totally degloved hand.

Keyword

Total degloving amputation; Hand; Untailored; Composite graft

Figure

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  Fig. 1. (A) Preoperative photo showing total degloving amputation from wrist to fingertips of the right hand. (B) Preoperative plain X-ray, showing bony amputation on the index finger at the DIP joint level, and on the distal phalanx shaft level of thumb, middle, and ring fingers.

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  Fig. 2. Follow-up photo showing initial color changes of the skin. (A) On the postoperative day (POD) 1, the skin flap was pale without any sign of circulation, and blanching was not found. (B) On POD 4, the skin showed bright red hue around the dorsum of the hand and proximal phalangeal level of digits. (C) On POD 7, the area showing red hue extended to the palmar side of the hand and vague blanching was seen on the adapted skin.

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  Fig. 3. At the 5th postoperative week, debridement and open amputation were done. Sixty-five percent of the adapted stump has survived, and minimal open amputation was done at the fingertip of the thumb, and distal to DIP joints of the index, middle, and ring fingers.

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  Fig. 4. Split-thickness skin graft (STSG) and anteromedial thigh (AMT)-bridged free flap was applied after open amputation. (A) Follow-up photo on the postoperative day 5 showing STSG grafted on dorsum and palmar side of the hand. (B) Immediate postoperative photo of AMT-bridged free flap on index, middle, and ring fingertips.

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  Fig. 5. Follow-up photo after 2 years 6 months from initial composite graft. Successful coverage was done by preserving the functional length of digits. The skin maintained pliability without any sign of significant contracture.

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  Fig. 6. Follow-up photo after 17 months, showing an active range of motion on digits. (A) The index, middle, ring, and small fingers reached nearly 90° at active flexion and 10° at extension on metacarpophalangeal (MCP) joints, and 40° at flexion and 20° at the extension on proximal interphalangeal joints. (B) For the thumb, the MCP joint showed 70° at flexion and 40° at extension. Besides, 40° of radial abduction and nearly 60% of normal opposition were recovered.

Reference

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