When a severe accident causes the skin to be forcefully stripped away from the underlying tissues, it represents one of the most devastating forms of soft-tissue trauma. Such wounds are characterized by extensive damage and are invariably the result of high-energy forces that physically tear tissue planes apart. The immediate consequence is a life-threatening compromise of the injured area, necessitating urgent and specialized medical intervention. The long-term outcome often involves complex surgical reconstruction or, in severe cases, the removal of the affected limb.
Identifying the Specific Injury: Degloving
The traumatic event described, where skin is peeled off, has a precise medical designation known as a degloving injury, or an avulsion. This term originates from the injury’s appearance, which resembles the act of pulling a glove off a hand or finger. Medically, degloving is the forcible separation of the skin and the layer of fat immediately beneath it, the subcutaneous tissue, from the deep fascia, muscle, or bone underneath.
The mechanism of this separation is a powerful shearing force that disrupts the attachments between tissue layers. This tearing action severs the network of small blood vessels, known as perforators, that supply the skin. Once the skin flap is separated, it is deprived of its blood supply, creating a vascular insult. This loss of circulation makes the avulsed tissue non-viable and highly susceptible to necrosis and infection if not addressed immediately by a surgical team.
Traumatic Mechanisms and Common Causes
Degloving injuries are almost exclusively caused by sudden, extreme mechanical forces that generate significant shear and rotational stress. The most common scenarios involve high-energy trauma, often including motor vehicle accidents, particularly those involving motorcycles or pedestrians being struck by a vehicle. In these instances, the limb or torso is subjected to a crushing and grinding force that tears the skin away from the deeper structures.
Industrial and agricultural accidents are also frequent causes, typically involving limbs becoming entangled in machinery, conveyor belts, or rotating equipment. The friction and torque generated by these mechanisms are sufficient to overcome the skin’s tensile strength and detach it from the underlying fascia. Degloving occurs most often in the lower extremities, such as the legs, due to their frequent exposure in high-impact trauma. The scalp, torso, and hands are also vulnerable locations.
The severity of the injury depends on the force applied and the extent of tissue separation. When the trauma is multiplanar, tissues are disrupted not only between the skin and fascia but also between muscle groups and even muscle and bone. Such extensive damage indicates a massive zone of injury, significantly increasing the complexity of any potential reconstruction effort.
Categorizing Severity: Open vs. Closed Injuries
Surgeons classify degloving injuries into two main categories: open and closed. An open degloving injury is the most visually obvious type, where the skin is torn away from the body, leaving the underlying muscle, tendons, or bone exposed. The avulsed skin may be completely missing or may remain partially attached as a non-viable flap of tissue near the wound.
A closed degloving injury is more subtle and often overlooked, where the skin remains externally intact. This internal trauma is known as a Morel-Lavallée lesion, typically forming in areas like the hip, thigh, or torso. The deep tissue separation creates a potential space that quickly fills with blood, lymph fluid, and necrotic fat, forming a fluid-filled pocket or hematoma.
While the skin surface appears unbroken, the underlying separation still compromises the blood supply to the overlying skin, risking tissue death. This internal fluid collection is also a breeding ground for potential infection, particularly if an underlying bone fracture is present. The classification system helps determine the required intervention, ranging from simple drainage for smaller closed injuries to complex surgical reconstruction for large, open wounds.
Surgical Outcomes: Reconstruction or Amputation
The outcome depends on the extent of damage to the underlying structures and the viability of the stripped skin. The decision to proceed with an amputation is made when the limb is deemed unsalvageable because the injury is too extensive, or the risk of life-threatening infection is too high. This is often the case in severe, circumferential degloving where the blood supply to the entire section of the limb is irreversibly destroyed.
Studies have shown that a significant percentage of patients with degloving soft tissue injuries, especially those with associated fractures, require amputation. For potentially salvageable limbs, the focus shifts to complex reconstruction aimed at preserving function and covering the wound. The most common technique involves debridement—the surgical removal of all dead or contaminated tissue—necessary to prevent infection and necrosis.
Following debridement, surgeons attempt to cover the exposed tissue using various methods. If the avulsed skin flap is deemed viable, it may be cleaned and reattached, a process known as replantation or revascularization. More often, the non-viable skin is discarded, and the wound is covered using split-thickness skin grafts harvested from the patient’s body. For deeper or more complex defects, a free flap procedure may be necessary, involving the transfer of healthy tissue, including muscle and blood vessels, from a distant site using microvascular surgery.