A degloving injury is a severe form of trauma involving the forcible separation of the skin and underlying soft tissue from deeper structures, such as muscle, bone, or fascia. The name comes from the injury’s appearance, which resembles a glove being peeled off a hand. This trauma violently disrupts the blood vessels, nerves, and connective tissues supplying the skin, leading to immediate tissue death if blood flow is not quickly restored. A degloved hand injury is concerning due to the hand’s complex anatomy, where delicate tendons and nerves are suddenly exposed.
Defining a Degloving Injury
A degloving injury, or avulsion, occurs when a strong shearing force tears the superficial soft tissue layers away from the deep fascia. The hand is susceptible because its skin is anchored at specific points, making the layers between them vulnerable to tangential trauma. The separation occurs just above the deep fascia, which covers muscles and bone. This detachment immediately deprives the avulsed skin of its blood supply, causing it to become non-viable quickly.
There are two primary classifications for this injury. An open degloving injury is the more dramatic type, where the skin is completely torn away or left hanging as a flap, exposing the structures beneath. This results in a large, open wound where bone, tendons, and nerves may be visible, leading to immediate concerns for infection and severe blood loss.
The second type is a closed degloving injury, often called a Morel-Lavallée lesion, which is less common in the hand. Here, the skin remains intact but the underlying layers separate internally, creating a pocket that fills with blood, lymph fluid, and fat. This causes swelling and bruising. However, the open degloving injury is the more frequent concern for the hand due to its slender structure.
How Degloving Injuries Occur
Degloving injuries of the hand result from high-energy mechanisms involving a shearing or tangential force. These injuries commonly occur in industrial or agricultural settings where machinery, such as rollers, gears, or conveyor belts, catches the hand. The pulling action of these mechanisms generates the friction and force necessary to mechanically strip the soft tissues.
Another cause is vehicular trauma, particularly accidents involving motorcycles or bicycles, where a limb is dragged along a road surface. This friction creates a severe abrasion injury combined with a shearing force that strips the skin and soft tissue. The injury is often compounded by contaminants embedded in the wound, such as dirt and debris, which increase the risk of infection.
A specific and common form is the ring avulsion injury, involving a finger caught on a moving or stationary object. When a ring is snagged, the body’s momentum pulls the finger, and the ring applies a circumferential force that rapidly strips the skin and soft tissue. This can range from a simple tear to the complete degloving and amputation of the finger.
Acute Surgical Repair and Treatment
The immediate surgical priority is to stabilize the patient, assess the tissue damage, and achieve wound coverage. Surgeons must first thoroughly clean the injury through debridement to remove all non-viable tissue and foreign contaminants, preventing infection. Simultaneously, the viability of the degloved skin and the status of underlying structures, including arteries, veins, nerves, and tendons, is assessed.
If the avulsed skin flap is relatively intact, the surgeon may attempt replantation or revascularization using microsurgical techniques to restore blood flow. However, the shearing mechanism often causes irreparable damage to the small blood vessels, making this approach often unsuccessful. If the hand or finger is extensively damaged with deep structural compromise, a decision between limb salvage and necessary amputation must be made to ensure the best long-term functional outcome.
For skin coverage, the primary surgical options are skin grafting or tissue flaps. Skin grafting involves transplanting a thin layer of skin from a donor site, such as the thigh, to the wound bed. This is viable only if the recipient site has a well-vascularized base; exposed bone or tendon cannot be covered by a skin graft alone. When deeper structures are exposed, a tissue flap is required, which transfers skin and subcutaneous tissue along with its own blood supply.
Types of Tissue Flaps
Flaps can be local, drawn from adjacent tissue, or distant. Distant flaps, such as a groin or abdominal flap, temporarily tack the hand to another body part for three to four weeks. This allows the tissue to establish a new blood supply before the flap is surgically detached.
Long-Term Recovery and Functional Outcomes
The post-surgical phase initiates a prolonged period of rehabilitation focused on maximizing function and mitigating the effects of scar tissue. Physical and occupational therapy must begin as soon as the surgical wounds are stable, involving daily hand exercises to prevent joint stiffness and tendon adhesion. Custom splinting is used to maintain the hand and fingers in an optimal position for healing and to aid in controlled movement.
Scar management is a continuous process to soften the tissue and reduce contractures that limit movement. This includes:
- Massage
- Pressure garments
- Silicone sheeting
Patients commonly experience sensory deficits, including numbness or hypersensitivity, due to nerve damage. Re-education techniques help the brain interpret new sensory signals as the nerves slowly regenerate, a process that can take many months or years.
Secondary surgeries are often necessary to refine the reconstructed hand. These may involve procedures like flap thinning, scar revision, or tendon transfers to improve dexterity and grip strength. Long-term functional outcomes are monitored using objective measures like grip strength and two-point discrimination, which tests the ability to distinguish two separate points of pressure. While a return to a high level of function is the goal, some permanent loss of fine motor skills, strength, or sensation is common, requiring patients to adapt.